Healthcare Provider Details

I. General information

NPI: 1972059780
Provider Name (Legal Business Name): VIA COGNITIVE HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 CENTRAL AVE
AUGUSTA GA
30904
US

IV. Provider business mailing address

1901 CENTRAL AVE
AUGUSTA GA
30904-4125
US

V. Phone/Fax

Practice location:
  • Phone: 706-738-5039
  • Fax: 706-364-1288
Mailing address:
  • Phone: 906-738-5039
  • Fax: 706-364-1288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number121R0030
License Number StateGA

VIII. Authorized Official

Name: JENNIFER PENNINGTON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 706-738-5039