Provider Demographics
NPI:1881258994
Name:GEORGIA CAROLINA ORTHOTIC CENTERS LLC
Entity type:Organization
Organization Name:GEORGIA CAROLINA ORTHOTIC CENTERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:CO, LO
Authorized Official - Phone:706-496-3911
Mailing Address - Street 1:2301 WRIGHTSBORO RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-6219
Mailing Address - Country:US
Mailing Address - Phone:706-496-3911
Mailing Address - Fax:706-496-2148
Practice Address - Street 1:2301 WRIGHTSBORO RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6219
Practice Address - Country:US
Practice Address - Phone:706-496-3911
Practice Address - Fax:706-496-2148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003210294AMedicaid