Provider Demographics
NPI:1932431525
Name:GENCARE OF GEORGIA, INC.
Entity Type:Organization
Organization Name:GENCARE OF GEORGIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:EXIE
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:BUFFINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-276-2273
Mailing Address - Street 1:PO BOX 1119
Mailing Address - Street 2:
Mailing Address - City:EAST ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30539
Mailing Address - Country:US
Mailing Address - Phone:706-276-2273
Mailing Address - Fax:706-276-2277
Practice Address - Street 1:11 KIKER ST
Practice Address - Street 2:
Practice Address - City:EAST ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540
Practice Address - Country:US
Practice Address - Phone:706-276-2273
Practice Address - Fax:706-276-2277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-05
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003104485AMedicaid