=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679744726
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST GA HEALTH DISTRICT 1-1
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2008
-----------------------------------------------------
Last Update Date | 03/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1309 REDMOND CIR NW
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30165-1307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-295-6571
-----------------------------------------------------
Fax | 706-295-6792
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1309 REDMOND CIR NW
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30165-1307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-295-6571
-----------------------------------------------------
Fax | 706-295-6792
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | SHERRY G HAMILTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-295-6571
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number | DPH000004
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number | 12288
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------