Provider Demographics
NPI:1053422428
Name:THE LONGSTREET CLINIC PC
Entity type:Organization
Organization Name:THE LONGSTREET CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:LOWE
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-718-1122
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-535-7445
Practice Address - Street 1:725 JESSE JEWELL PKWY SE STE 395
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3834
Practice Address - Country:US
Practice Address - Phone:770-533-6680
Practice Address - Fax:770-533-6681
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE LONGSTREET CLINIC, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-31
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1154222OtherNCPDP PROVIDER IDENTIFICATION NUMBER
GA439568713BMedicaid
GA439568713AMedicaid
1154222OtherNCPDP PROVIDER IDENTIFICATION NUMBER