=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114987393
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST GEORGIA THERAPY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 NORTH AVE
-----------------------------------------------------
City | VILLA RICA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30180-1206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-456-3472
-----------------------------------------------------
Fax | 770-456-3230
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 NORTH AVE
-----------------------------------------------------
City | VILLA RICA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30180-1206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-456-3472
-----------------------------------------------------
Fax | 770-456-3230
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT
-----------------------------------------------------
Name | MR. GEORGE BO HAMIL JR.
-----------------------------------------------------
Credential | MPT
-----------------------------------------------------
Telephone | 770-832-2484
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------