Provider Demographics
NPI:1861513129
Name:SPALDING REGIONAL URGENT CARE CENTER AT HERON BAY, L.L.C.
Entity type:Organization
Organization Name:SPALDING REGIONAL URGENT CARE CENTER AT HERON BAY, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP OF OUTPATIENT SERVICES, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:BURTNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-893-2153
Mailing Address - Street 1:3334 HIGHWAY 155 SOUTH
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248
Mailing Address - Country:US
Mailing Address - Phone:678-583-0241
Mailing Address - Fax:678-583-0261
Practice Address - Street 1:3334 HIGHWAY 155 SOUTH
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248
Practice Address - Country:US
Practice Address - Phone:678-583-0241
Practice Address - Fax:678-583-0261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G700165Medicare PIN
GADP0931Medicare PIN