Provider Demographics
NPI:1760959175
Name:NORTHWEST GEORGIA REGIONAL COMMISSION AREA AGENCY
Entity Type:Organization
Organization Name:NORTHWEST GEORGIA REGIONAL COMMISSION AREA AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, AREA AGENCY ON AGING
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:L
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD
Authorized Official - Phone:706-295-6485
Mailing Address - Street 1:PO BOX 1798
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-1798
Mailing Address - Country:US
Mailing Address - Phone:706-295-6485
Mailing Address - Fax:706-802-5508
Practice Address - Street 1:1 JACKSON HILL DR NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-5205
Practice Address - Country:US
Practice Address - Phone:706-295-6485
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003181509Medicaid