Healthcare Provider Details

I. General information

NPI: 1033644067
Provider Name (Legal Business Name): HGA VILLA RICA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2017
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 BANKHEAD HWY
CARROLLTON GA
30117-3425
US

IV. Provider business mailing address

PO BOX 6084
DOUGLASVILLE GA
30154-0019
US

V. Phone/Fax

Practice location:
  • Phone: 770-838-8440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number40639
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number40639
License Number StateGA

VIII. Authorized Official

Name: VAUGHN S CLAGETTE
Title or Position: PARTNER
Credential: MD
Phone: 770-838-8440