Provider Demographics
NPI:1366844367
Name:MIDDLE GEORGIA FAMILY REHAB
Entity Type:Organization
Organization Name:MIDDLE GEORGIA FAMILY REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-956-4916
Mailing Address - Street 1:100 HAMILTON POINTE DR
Mailing Address - Street 2:P.O. BOX 1552
Mailing Address - City:BYRON
Mailing Address - State:GA
Mailing Address - Zip Code:31008
Mailing Address - Country:US
Mailing Address - Phone:478-956-4916
Mailing Address - Fax:
Practice Address - Street 1:100 HAMILTON POINTE DR.
Practice Address - Street 2:SUITE 115 & 120
Practice Address - City:BYRON
Practice Address - State:GA
Practice Address - Zip Code:31008
Practice Address - Country:US
Practice Address - Phone:478-956-4916
Practice Address - Fax:478-956-0958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT002436302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization