Provider Demographics
NPI:1215088174
Name:COLQUITT FAMILY CARE, INC.
Entity type:Organization
Organization Name:COLQUITT FAMILY CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:MANOUTCHEHER
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-891-2170
Mailing Address - Street 1:2801 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6908
Mailing Address - Country:US
Mailing Address - Phone:229-891-2170
Mailing Address - Fax:
Practice Address - Street 1:2801 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6908
Practice Address - Country:US
Practice Address - Phone:229-891-2170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043008261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA85001900GMedicaid
GAG46627Medicare UPIN
GA85001900GMedicaid