MEDICARE: SIGNATURE CARE 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	CLA002022	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	:	1295058378
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIGNATURE CARE OF GEORGIA LLC

Provider Business Mailing Address
First Line	:	PO BOX 80044
Second Line	:
City	:	ATHENS
State	:	GA
Zip	:	30608-0044
Country	:	US
Telephone Number	:	706-224-4531
Fax Number	:

Provider Business Practice Location Address
First Line	:	172 HERRING ST
Second Line	:
City	:	ATHENS
State	:	GA
Zip	:	30601-3148
Country	:	US
Telephone Number	:	706-224-4531
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	MR. MICHAEL POPE
Credential	:
Telephone Number	:	678-485-2527

Provider Enumeration Date	:	03/03/2010
Last Update Date	:	03/31/2016

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