Provider Demographics
NPI:1912545153
Name:HEALTHIE GEORGIA CORPORATION
Entity Type:Organization
Organization Name:HEALTHIE GEORGIA CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:RENFRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-782-0764
Mailing Address - Street 1:456 BULL FROG LN
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525-4064
Mailing Address - Country:US
Mailing Address - Phone:904-382-0925
Mailing Address - Fax:
Practice Address - Street 1:821 S MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-0163
Practice Address - Country:US
Practice Address - Phone:912-366-9371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-18
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA332370125GMedicaid