Provider Demographics
NPI:1871292078
Name:KING'S HOMETOWN WALK-IN CLINIC LLC
Entity type:Organization
Organization Name:KING'S HOMETOWN WALK-IN CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEARD-ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-206-1162
Mailing Address - Street 1:214 YOUNG HARRIS ST STE B
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-8534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:214 YOUNG HARRIS ST STE B
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-8534
Practice Address - Country:US
Practice Address - Phone:706-400-9770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty