Provider Demographics
NPI:1588750947
Name:DALTON OUTPATIENT CENTER DAL DIAGNOSTIC ASSOC LP
Entity type:Organization
Organization Name:DALTON OUTPATIENT CENTER DAL DIAGNOSTIC ASSOC LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RADIOLOGIST GENERAL PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CLAYTON
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-278-9729
Mailing Address - Street 1:PO BOX 1207
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30722-1207
Mailing Address - Country:US
Mailing Address - Phone:706-278-9729
Mailing Address - Fax:706-226-9378
Practice Address - Street 1:1502 NORTH THORNTON AVE
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720
Practice Address - Country:US
Practice Address - Phone:706-278-9729
Practice Address - Fax:706-226-9378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACM5117OtherRAILROAD MEDICARE
GA00248245FMedicaid
GA00248245FMedicaid