MEDICARE: GEORGIA LIVING AT HOME, 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1760086102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA LIVING AT HOME, LLC

Provider Business Mailing Address
First Line	:	203 DONEHOO STREET
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30458-5120
Country	:	US
Telephone Number	:	912-764-4459
Fax Number	:	912-489-1975

Provider Business Practice Location Address
First Line	:	203 DONEHOO STREET
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30458-5120
Country	:	US
Telephone Number	:	912-764-4459
Fax Number	:	912-489-1975

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MR. JAMES WESLEY WIGGINS III
Credential	:
Telephone Number	:	912-764-4459

Provider Enumeration Date	:	11/25/2020
Last Update Date	:	06/10/2025

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