Provider Demographics
NPI:1104066265
Name:TMC/VILLA RICA HOSPITAL, INC
Entity type:Organization
Organization Name:TMC/VILLA RICA HOSPITAL, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHERSETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-836-9697
Mailing Address - Street 1:PO BOX 638
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-0638
Mailing Address - Country:US
Mailing Address - Phone:770-836-9666
Mailing Address - Fax:770-456-3390
Practice Address - Street 1:601 DALLAS HWY
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1202
Practice Address - Country:US
Practice Address - Phone:770-456-3000
Practice Address - Fax:770-456-3390
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TMC/VILLA RICA HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-03
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000002032AMedicaid
GA000002032AMedicaid