Provider Demographics
NPI:1720052863
Name:LAGRANGE TROUP COUNTY HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:LAGRANGE TROUP COUNTY HOSPITAL AUTHORITY
Other - Org Name:WEST GEORGIA HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:N
Authorized Official - Last Name:FULKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-845-3244
Mailing Address - Street 1:1514 VERNON RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4131
Mailing Address - Country:US
Mailing Address - Phone:706-845-3291
Mailing Address - Fax:706-845-3902
Practice Address - Street 1:120 GLENN BASS RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-5809
Practice Address - Country:US
Practice Address - Phone:706-845-3291
Practice Address - Fax:706-845-3902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00145681AMedicaid
GA00145681AMedicaid