Organization
OUR LADY OF THE ROSES PRIMARY CARE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. GERALD WILLIAM WIECZOREK (BUSINESS MANAGER)
(706) 327-4880
Entity
Organization
Contact information
Practice address
808 21ST ST, COLUMBUS, GA 31904-8817
(706) 587-5771
Mailing address
PO BOX 1957, FORTSON, GA 31808-1957
(706) 587-5771
Taxonomy
Speciality
Code
Description
License number
State
261QM1000X
Migrant Health Clinic/Center
Primary
RN042301
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000901106D
—
GA
05
—
126693
—
AL
Enumeration date
10/07/2015
Last updated
10/07/2015
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