Provider Demographics
NPI:1114987393
Name:WEST GEORGIA THERAPY CENTER, LLC
Entity Type:Organization
Organization Name:WEST GEORGIA THERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:BO
Authorized Official - Last Name:HAMIL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MPT
Authorized Official - Phone:770-832-2484
Mailing Address - Street 1:605 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1206
Mailing Address - Country:US
Mailing Address - Phone:770-456-3472
Mailing Address - Fax:770-456-3230
Practice Address - Street 1:605 NORTH AVE
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1206
Practice Address - Country:US
Practice Address - Phone:770-456-3472
Practice Address - Fax:770-456-3230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116797Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER