Provider Demographics
NPI:1720300387
Name:FAMILY FIRST HEALTHCARE OF NORTHEAST GEORGIA
Entity type:Organization
Organization Name:FAMILY FIRST HEALTHCARE OF NORTHEAST GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:706-356-8181
Mailing Address - Street 1:11973 AUGUSTA RD
Mailing Address - Street 2:
Mailing Address - City:LAVONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30553-1283
Mailing Address - Country:US
Mailing Address - Phone:706-356-8181
Mailing Address - Fax:706-356-8081
Practice Address - Street 1:11973 AUGUSTA RD
Practice Address - Street 2:
Practice Address - City:LAVONIA
Practice Address - State:GA
Practice Address - Zip Code:30553-1283
Practice Address - Country:US
Practice Address - Phone:706-356-8181
Practice Address - Fax:706-356-8081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-24
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN144697NP363LA2100X, 363LC0200X, 363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care MedicineGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC132982Medicaid
GA85001253GMedicaid
GA85001253GMedicaid