Provider Demographics
NPI:1679132922
Name:JUDY B BAIN
Entity type:Organization
Organization Name:JUDY B BAIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ROXIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-594-6073
Mailing Address - Street 1:104 HARWELL AVE STE 236
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-3132
Mailing Address - Country:US
Mailing Address - Phone:706-885-0111
Mailing Address - Fax:706-885-0607
Practice Address - Street 1:104 HARWELL AVE STE 236
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3132
Practice Address - Country:US
Practice Address - Phone:706-885-0111
Practice Address - Fax:706-885-0607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center