Provider Demographics
NPI:1992910749
Name:K12 CLINICS
Entity type:Organization
Organization Name:K12 CLINICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ADEREMI
Authorized Official - Middle Name:S
Authorized Official - Last Name:DOSUNMU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-877-7924
Mailing Address - Street 1:938 E.G. MILES PARKWAY
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313
Mailing Address - Country:US
Mailing Address - Phone:912-877-7924
Mailing Address - Fax:912-877-5437
Practice Address - Street 1:938 ELMA G. MILES PARKWAY
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313
Practice Address - Country:US
Practice Address - Phone:912-877-7924
Practice Address - Fax:912-877-5437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047893261QM0801X, 261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health