=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932991791
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGIA MOUNTAINS HEALTH SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2025
-----------------------------------------------------
Last Update Date | 05/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4038 E HIGHWAY 136
-----------------------------------------------------
City | LA FAYETTE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30728-6041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-517-6756
-----------------------------------------------------
Fax | 706-517-4281
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 165 BLUE RIDGE OVERLOOK
-----------------------------------------------------
City | BLUE RIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30513-4431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-946-5607
-----------------------------------------------------
Fax | 706-374-7628
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | STEVEN MIRACLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-946-5610
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------