Provider Demographics
NPI:1841328135
Name:ICFMR AT GEORGIA REGIONAL HOSPITAL ATLANTA
Entity type:Organization
Organization Name:ICFMR AT GEORGIA REGIONAL HOSPITAL ATLANTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATION OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SONNY
Authorized Official - Middle Name:
Authorized Official - Last Name:SLATE
Authorized Official - Suffix:
Authorized Official - Credentials:COO
Authorized Official - Phone:404-243-2121
Mailing Address - Street 1:P.O. BOX 370407
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-3828
Mailing Address - Country:US
Mailing Address - Phone:404-243-2158
Mailing Address - Fax:404-243-2159
Practice Address - Street 1:3073 PANTHERSVILLE ROAD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-3828
Practice Address - Country:US
Practice Address - Phone:404-243-2158
Practice Address - Fax:404-243-2159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
314000000X
GA2044856315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00141061AMedicaid