=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821077017
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEARTH HEALTHCARE OF GEORGIA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2006
-----------------------------------------------------
Last Update Date | 05/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 93 CRYE LEIKE DR
-----------------------------------------------------
City | FORT OGLETHORPE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30742-4055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-866-9854
-----------------------------------------------------
Fax | 706-858-9371
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 FAULCONER DR STE 200
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22903-5089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-977-9711
-----------------------------------------------------
Fax | 434-235-4142
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF ADMINISTRATIVE OFFICER
-----------------------------------------------------
Name | JESSE R MOORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 857-331-6271
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------