| Victoria Family Practice Clinic, Llc | |
|
23 Lester Rd Statesboro GA 30458-4700 | |
| (912) 225-1836 | |
| (912) 225-0645 |
| Full Name | Victoria Family Practice Clinic, Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 23 Lester Rd, Statesboro, Georgia |
| Authorized Official Name and Position | Osaretin Daniel Okungbowa (OWNER) |
| Authorized Official Contact | 9122251836 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Victoria Family Practice Clinic, Llc 23 Lester Rd Statesboro GA 30458-4700 Ph: (912) 225-1836 | Victoria Family Practice Clinic, Llc 23 Lester Rd Statesboro GA 30458-4700 Ph: (912) 225-1836 |
| NPI Number | 1700119997 |
|---|---|
| Provider Enumeration Date | 09/07/2009 |
| Last Update Date | 01/20/2012 |
| Medicare PECOS PAC ID | 8729124854 |
|---|---|
| Medicare Enrollment ID | O20091005000068 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1700119997 | NPI | - | NPPES |
| 420313629A | Medicaid | GA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | 062926 (Georgia) | Primary |
| Provider Name | Amy D Clemons |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1225122435 PECOS PAC ID: 8921006495 Enrollment ID: I20061116000247 |
| Provider Name | Osaretin Okungbowa |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1740474154 PECOS PAC ID: 3678627999 Enrollment ID: I20091005000058 |
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