=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245672724
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDDLE GEORGIA FAMILY REHAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2013
-----------------------------------------------------
Last Update Date | 10/31/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 HAMILTON POINTE DRIVE 115
-----------------------------------------------------
City | BYRON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-538-1436
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 1552 115
-----------------------------------------------------
City | BYRON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-845-3520
-----------------------------------------------------
Fax | 478-956-0958
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | BRENDA HICKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 478-538-1436
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0401X
-----------------------------------------------------
Taxonomy Name | Comprehensive Outpatient Rehabilitation Facility (CORF)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------