Provider Demographics
NPI:1043352958
Name:CESAR CLINIC, LLC
Entity type:Organization
Organization Name:CESAR CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CESAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-871-8500
Mailing Address - Street 1:1497 FAIR RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0822
Mailing Address - Country:US
Mailing Address - Phone:912-871-8500
Mailing Address - Fax:912-871-8508
Practice Address - Street 1:1497 FAIR RD
Practice Address - Street 2:SUITE 201
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0822
Practice Address - Country:US
Practice Address - Phone:912-871-8500
Practice Address - Fax:912-871-8508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF63922174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00867974AMedicaid
GA00867974AMedicaid
GAGRP6730Medicare ID - Type Unspecified