Provider Demographics
NPI:1316683212
Name:MOM-YKK CLINIC
Entity type:Organization
Organization Name:MOM-YKK CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BEVILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-751-2925
Mailing Address - Street 1:124 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-3404
Mailing Address - Country:US
Mailing Address - Phone:478-751-2925
Mailing Address - Fax:
Practice Address - Street 1:3340 CHESTNEY RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-5502
Practice Address - Country:US
Practice Address - Phone:478-972-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MACON OCCUPATIONAL MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Single Specialty