Provider Demographics
NPI:1275649410
Name:GEORGIA DEPT OF HUMAN RESOURCES
Entity Type:Organization
Organization Name:GEORGIA DEPT OF HUMAN RESOURCES
Other - Org Name:PHOENIX CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL HOSPITAL ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-445-4128
Mailing Address - Street 1:2125 VINSON HWY
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31062-7525
Mailing Address - Country:US
Mailing Address - Phone:478-445-4128
Mailing Address - Fax:
Practice Address - Street 1:2125 VINSON HWY
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31062-7525
Practice Address - Country:US
Practice Address - Phone:478-445-4128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00442824AMedicaid