Basic Information
| Provider Information | |||||||||
| NPI: | 1104066265 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TMC/VILLA RICA HOSPITAL, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WILLOWBROOKE AT TANNER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 638 | ||||||||
| Address2: | |||||||||
| City: | VILLA RICA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301800638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708369666 | ||||||||
| FaxNumber: | 7704563390 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 DALLAS HWY | ||||||||
| Address2: | |||||||||
| City: | VILLA RICA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301801202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704563000 | ||||||||
| FaxNumber: | 7704563390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2009 | ||||||||
| LastUpdateDate: | 07/28/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHERSETH | ||||||||
| AuthorizedOfficialFirstName: | LEE | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7708369697 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TMC/VILLA RICA HOSPITAL, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 000002032A | 05 | GA | MEDICAID |