Provider Demographics
NPI:1124638614
Name:PMS 68 LLC
Entity type:Organization
Organization Name:PMS 68 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HARBIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-378-2214
Mailing Address - Street 1:235 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39828-2118
Mailing Address - Country:US
Mailing Address - Phone:229-378-2214
Mailing Address - Fax:833-386-7012
Practice Address - Street 1:235 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828-2118
Practice Address - Country:US
Practice Address - Phone:229-378-2214
Practice Address - Fax:833-386-7012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-09
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0009544125Medicaid