Provider Demographics
NPI:1730329806
Name:JW MEDICAL CARE, LLC
Entity type:Organization
Organization Name:JW MEDICAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:S.
Authorized Official - Middle Name:LOGAN
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-252-2137
Mailing Address - Street 1:PO BOX 1016
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-1016
Mailing Address - Country:US
Mailing Address - Phone:678-252-2137
Mailing Address - Fax:678-336-7099
Practice Address - Street 1:2225 GODBY RD
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-5012
Practice Address - Country:US
Practice Address - Phone:404-767-8274
Practice Address - Fax:404-768-8035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-02
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA910871089BMedicaid
GA511G701302OtherMEDICARE GROUP NUMBER