Provider Demographics
NPI:1790924918
Name:EAST GEORGIA HEALTHCARE CENTER, INC.
Entity Type:Organization
Organization Name:EAST GEORGIA HEALTHCARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:R
Authorized Official - Last Name:SORRELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-237-6262
Mailing Address - Street 1:215 N COLEMAN ST
Mailing Address - Street 2:
Mailing Address - City:SWAINSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30401-3530
Mailing Address - Country:US
Mailing Address - Phone:478-237-6262
Mailing Address - Fax:478-237-9138
Practice Address - Street 1:118 ALICE COLEMAN DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8860
Practice Address - Country:US
Practice Address - Phone:912-537-6565
Practice Address - Fax:912-537-6161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000632376LMedicaid
GA000632376LMedicaid