Provider Demographics
NPI:1780666321
Name:INTREPID OF GEORGIA, INC.
Entity type:Organization
Organization Name:INTREPID OF GEORGIA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CCO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-445-3750
Mailing Address - Street 1:14841 DALLAS PKWY STE 625
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-7641
Mailing Address - Country:US
Mailing Address - Phone:214-542-4952
Mailing Address - Fax:214-445-3902
Practice Address - Street 1:2510 ARCHWOOD DR
Practice Address - Street 2:SUITES 11 & 12
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-6623
Practice Address - Country:US
Practice Address - Phone:229-430-8878
Practice Address - Fax:229-430-9920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047276H251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA392849492AMedicaid
GA392849492AMedicaid