Organization
PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL, LLC
Active
Parent organization
PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL, LLC
Other names
Southern Regional Medical Center
Organization subpart
Yes
Provider details
NPI number
Legal business name
PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL, LLC
Authorized official
CHRISTOPHER DOAN (COMPLIANCE OFFICER)
(310) 259-4706
Entity
Organization
Contact information
Practice address
11 UPPER RIVERDALE RD SW, RIVERDALE, GA 30274-2615
(770) 991-8160
(770) 909-2595
Mailing address
11 UPPER RIVERDALE RD SW, RIVERDALE, GA 30274-2615
(770) 991-8160
(770) 909-2595
Taxonomy
Speciality
Code
Description
License number
State
273R00000X
Psychiatric Hospital Unit
Primary
031-710
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000000404A
—
GA
Enumeration date
09/10/2018
Last updated
09/10/2018
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