=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184870594
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOSPITAL AMBULANCE OF GEORGIA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2008
-----------------------------------------------------
Last Update Date | 08/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 181B SW UPPER RIVERDALE RD
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30274-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-229-1617
-----------------------------------------------------
Fax | 770-490-0038
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1117
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30214-6117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-719-5337
-----------------------------------------------------
Fax | 770-907-1588
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JAY NETTLES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-229-1617
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 031-21
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------