Provider Demographics
NPI:1225068612
Name:HOME HEALTH AGENCY OF GEORGIA LLC
Entity Type:Organization
Organization Name:HOME HEALTH AGENCY OF GEORGIA LLC
Other - Org Name:CAMELLIA HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILFORD
Authorized Official - Middle Name:A
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:601-544-2900
Mailing Address - Street 1:PO BOX 1956
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1956
Mailing Address - Country:US
Mailing Address - Phone:601-544-2900
Mailing Address - Fax:601-264-3512
Practice Address - Street 1:1705 ENTERPRISE WAY SE
Practice Address - Street 2:SUITE 102
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-9224
Practice Address - Country:US
Practice Address - Phone:678-354-1456
Practice Address - Fax:678-797-5761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA113093084AMedicaid
GA113093084AMedicaid