Provider Demographics
NPI:1639441744
Name:HOMETOWN HEALTHCARE, LLC
Entity Type:Organization
Organization Name:HOMETOWN HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HAGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-924-4156
Mailing Address - Street 1:1035 E FORSYTH ST
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-3721
Mailing Address - Country:US
Mailing Address - Phone:229-924-5200
Mailing Address - Fax:229-924-0073
Practice Address - Street 1:1035 E FORSYTH ST
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3721
Practice Address - Country:US
Practice Address - Phone:229-924-5200
Practice Address - Fax:229-924-0073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-04
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA118093363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA285996480DMedicaid