Provider Demographics
NPI:1063512945
Name:TIFTON ENDOSCOPY CENTER, INC.
Entity type:Organization
Organization Name:TIFTON ENDOSCOPY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEGHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-382-9338
Mailing Address - Street 1:1111 20TH ST E
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3689
Mailing Address - Country:US
Mailing Address - Phone:229-382-9338
Mailing Address - Fax:229-382-4282
Practice Address - Street 1:1111 20TH ST E
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3689
Practice Address - Country:US
Practice Address - Phone:229-382-9338
Practice Address - Fax:229-382-4282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA111094ASCA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00755675AMedicaid
GA00755675AMedicaid