Healthcare Provider Details

I. General information

NPI: 1265463004
Provider Name (Legal Business Name): HOSPITAL AUTHORITY OF LIBERTY COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 84 EAST
LUDOWICI GA
31316
US

IV. Provider business mailing address

RR 3 BOX 2D
LUDOWICI GA
31316-9701
US

V. Phone/Fax

Practice location:
  • Phone: 912-545-3392
  • Fax: 912-545-9588
Mailing address:
  • Phone: 912-545-3392
  • Fax: 912-545-9588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DEREK ROZIER
Title or Position: CFO
Credential:
Phone: 912-369-9427