Provider Demographics
NPI:1184870594
Name:HOSPITAL AMBULANCE OF GEORGIA, LLC
Entity type:Organization
Organization Name:HOSPITAL AMBULANCE OF GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:NETTLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-229-1617
Mailing Address - Street 1:PO BOX 1117
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-6117
Mailing Address - Country:US
Mailing Address - Phone:770-719-5337
Mailing Address - Fax:770-907-1588
Practice Address - Street 1:181B SW UPPER RIVERDALE RD
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-0000
Practice Address - Country:US
Practice Address - Phone:843-229-1617
Practice Address - Fax:770-490-0038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031-213416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport