=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972059780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIA COGNITIVE HEALTH, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2016
-----------------------------------------------------
Last Update Date | 03/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1901 CENTRAL AVE
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-738-5039
-----------------------------------------------------
Fax | 706-364-1288
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1901 CENTRAL AVE
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30904-4125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-738-5039
-----------------------------------------------------
Fax | 706-364-1288
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | JENNIFER PENNINGTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-738-5039
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number | 121R0030
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------