Provider Demographics
NPI:1073561130
Name:REGENCY HOSPICE OF GEORGIA, LLC
Entity Type:Organization
Organization Name:REGENCY HOSPICE OF GEORGIA, LLC
Other - Org Name:REGENCY HOSPICE OF NORTHEAST GEORGIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF LEGAL AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-664-2876
Mailing Address - Street 1:655 BRAWLEY SCHOOL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9125
Mailing Address - Country:US
Mailing Address - Phone:704-664-2876
Mailing Address - Fax:704-664-1306
Practice Address - Street 1:4255 WADE GREEN RD NW
Practice Address - Street 2:STE 210
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-1762
Practice Address - Country:US
Practice Address - Phone:770-382-7175
Practice Address - Fax:770-382-4927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008-191-H251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000457509AMedicaid
GA11-1604Medicare PIN