Healthcare Provider Details

I. General information

NPI: 1639166234
Provider Name (Legal Business Name): GA DEPARTMENT OF HUMAN RESOURCES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MYRTLE BLVD
GRACEWOOD GA
30812-1500
US

IV. Provider business mailing address

100 MYRTLE BLVD
GRACEWOOD GA
30812-1500
US

V. Phone/Fax

Practice location:
  • Phone: 706-790-2042
  • Fax: 706-790-2476
Mailing address:
  • Phone: 706-790-2042
  • Fax: 706-790-2476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1121694
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00140709A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: DR. GAIL C JACKSON
Title or Position: REGIONAL HOSPITAL ADMINISTRATOR
Credential: M.D.
Phone: 706-790-2030