MEDICARE: REGENCY HOSPICE OF GEORGIA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251G00000X	Community Based Hospice Care Agency	008-191-H	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073561130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REGENCY HOSPICE OF GEORGIA, LLC

Provider Business Mailing Address
First Line	:	655 BRAWLEY SCHOOL RD
Second Line	:	SUITE 200
City	:	MOORESVILLE
State	:	NC
Zip	:	28117-9125
Country	:	US
Telephone Number	:	704-664-2876
Fax Number	:	704-664-1306

Provider Business Practice Location Address
First Line	:	4255 WADE GREEN RD NW
Second Line	:	STE 210
City	:	KENNESAW
State	:	GA
Zip	:	30144-1762
Country	:	US
Telephone Number	:	770-382-7175
Fax Number	:	770-382-4927

Authorized Official
Title or Position	:	VP OF LEGAL AFFAIRS
Name	:	JESSICA KLEBERG
Credential	:
Telephone Number	:	704-664-2876

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	05/16/2016

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