Provider Demographics
NPI:1780094987
Name:SOUTH GA ORTHOPEDIC RESOURCES INC
Entity type:Organization
Organization Name:SOUTH GA ORTHOPEDIC RESOURCES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER/PART OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:BENTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LO,CO
Authorized Official - Phone:678-960-4424
Mailing Address - Street 1:1825 OLD OCILLA RD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-1617
Mailing Address - Country:US
Mailing Address - Phone:229-386-9829
Mailing Address - Fax:
Practice Address - Street 1:5152 BELLE WOOD CT STE G
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-5881
Practice Address - Country:US
Practice Address - Phone:678-960-4424
Practice Address - Fax:678-680-7903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-28
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAL.O. 14335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA057062934CMedicaid
GA5633920001Medicare NSC