Provider Demographics
NPI:1558343145
Name:FC OF GEORGIA INC
Entity Type:Organization
Organization Name:FC OF GEORGIA INC
Other - Org Name:INTREPID USA HEALTHCARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CCO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-445-3773
Mailing Address - Street 1:14841 DALLAS PKWY STE 625
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-7641
Mailing Address - Country:US
Mailing Address - Phone:214-542-4952
Mailing Address - Fax:214-445-3902
Practice Address - Street 1:355 NORTHSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1861
Practice Address - Country:US
Practice Address - Phone:229-247-7760
Practice Address - Fax:229-241-9806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA092275H251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000775541AMedicaid
117073Medicare Oscar/Certification