Healthcare Provider Details

I. General information

NPI: 1215135041
Provider Name (Legal Business Name): MGA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 KENNESAW AVE NW
MARIETTA GA
30060-1002
US

IV. Provider business mailing address

2979 PGA BLVD
PALM BEACH GARDENS FL
33410-2911
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-2451
  • Fax: 770-426-0462
Mailing address:
  • Phone: 561-627-0664
  • Fax: 561-627-2867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1-033-1720
License Number StateGA

VIII. Authorized Official

Name: MR. PAUL M WALCZAK
Title or Position: CEO
Credential:
Phone: 561-627-0664