Provider Demographics
NPI:1326191180
Name:PROFESSIONAL RESOURCES MANAGEMENT OF RABUN, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL RESOURCES MANAGEMENT OF RABUN, LLC
Other - Org Name:MOUNTAIN LAKES MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-782-0400
Mailing Address - Street 1:162 LEGACY PT
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525-5354
Mailing Address - Country:US
Mailing Address - Phone:706-782-3100
Mailing Address - Fax:706-782-6897
Practice Address - Street 1:162 LEGACY PT
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525-5354
Practice Address - Country:US
Practice Address - Phone:706-782-0401
Practice Address - Fax:706-782-0451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA119-621282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10063437OtherAMERIGROUP
GA293932OtherWELLCARE
GA00001559AMedicaid
GA0001559SMedicaid
GA51000340OtherBLUE CROSS OF GEORGIA
GA293932OtherWELLCARE
GAHOSP239Medicare Oscar/Certification
GA111336Medicare ID - Type UnspecifiedMEDICARE