Healthcare Provider Details

I. General information

NPI: 1780094987
Provider Name (Legal Business Name): SOUTH GA ORTHOPEDIC RESOURCES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5152 BELLE WOOD CT STE G
BUFORD GA
30518-5881
US

IV. Provider business mailing address

1825 OLD OCILLA RD
TIFTON GA
31794-1617
US

V. Phone/Fax

Practice location:
  • Phone: 678-960-4424
  • Fax: 678-680-7903
Mailing address:
  • Phone: 229-386-9829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberL.O. 14
License Number StateGA

VIII. Authorized Official

Name: MR. JAKE ERIC BENTLEY
Title or Position: MANAGER/PART OWNER
Credential: L.O.,C.O.
Phone: 678-960-4424