Provider Demographics
NPI:1346214996
Name:LAGRANGE TROUP COUNTY HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:LAGRANGE TROUP COUNTY HOSPITAL AUTHORITY
Other - Org Name:TWIN FOUNTAINS HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:N
Authorized Official - Last Name:FULKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-845-3244
Mailing Address - Street 1:1514 VERNON RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4131
Mailing Address - Country:US
Mailing Address - Phone:706-882-0121
Mailing Address - Fax:706-845-3902
Practice Address - Street 1:1400 HOGANSVILLE RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-1422
Practice Address - Country:US
Practice Address - Phone:706-882-0121
Practice Address - Fax:706-845-3902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00142843AMedicaid
GA00142843AMedicaid