# MIDDLE GEORGIA DIABETES ENDOCRINOLOGY WELLNESS CENTER, LLC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** MIDDLE GEORGIA HEART AND VASCULAR CENTER, LLC
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1205231636
- **Legal business name:** MIDDLE GEORGIA HEART AND VASCULAR CENTER, LLC
- **Authorized official:** MR. RALLIE DALE COGBURN SR. PA-C (OFFICE MANAGER)
- **Authorized official phone:** (478) 254-2644

## Contact information

- **Practice address:** 512 S HOUSTON LAKE RD, WARNER ROBINS, GA 31088-6308
- **Practice address phone:** (478) 254-2644
- **Practice address fax:** (478) 254-4924
- **Mailing address:** PO BOX 26790, MACON, GA 31221-6790
- **Mailing address phone:** (478) 254-2644
- **Mailing address fax:** (478) 254-4924

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207RE0101X | Endocrinology, Diabetes & Metabolism Physician | 66515 | GA | Yes |

## Other

- **Enumeration date:** 10/28/2014
- **Last updated:** 10/28/2014