Provider Demographics
NPI:1801093497
Name:TRI-COUNTY CLINIC, INC.
Entity type:Organization
Organization Name:TRI-COUNTY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:770-464-4434
Mailing Address - Street 1:551 N CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:SOCIAL CIRCLE
Mailing Address - State:GA
Mailing Address - Zip Code:30025-2887
Mailing Address - Country:US
Mailing Address - Phone:770-464-4434
Mailing Address - Fax:770-464-4424
Practice Address - Street 1:551 N CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:SOCIAL CIRCLE
Practice Address - State:GA
Practice Address - Zip Code:30025-2887
Practice Address - Country:US
Practice Address - Phone:770-464-4434
Practice Address - Fax:770-464-4424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA030580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000366638KMedicaid
GAD44844Medicare UPIN
GA000366638KMedicaid