Provider Demographics
NPI:1952967234
Name:PALMETTO HEALTH COUNCIL, INC.
Entity Type:Organization
Organization Name:PALMETTO HEALTH COUNCIL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:W
Authorized Official - Last Name:WOLLENZIEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DBA
Authorized Official - Phone:404-929-8824
Mailing Address - Street 1:643 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:GA
Mailing Address - Zip Code:30268-1138
Mailing Address - Country:US
Mailing Address - Phone:404-929-8824
Mailing Address - Fax:404-929-9769
Practice Address - Street 1:507 PARK ST
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:GA
Practice Address - Zip Code:30268-1007
Practice Address - Country:US
Practice Address - Phone:404-929-8824
Practice Address - Fax:404-929-9769
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALMETTO HEALTH COUNCIL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)