Provider Demographics
NPI:1306276498
Name:MT BERRY HOSPICE INC.
Entity type:Organization
Organization Name:MT BERRY HOSPICE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-907-7222
Mailing Address - Street 1:4300 MARTHA BERRY HWY NE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-8642
Mailing Address - Country:US
Mailing Address - Phone:706-232-1571
Mailing Address - Fax:706-232-1572
Practice Address - Street 1:4300 MARTHA BERRY HWY NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-8642
Practice Address - Country:US
Practice Address - Phone:706-232-1571
Practice Address - Fax:706-232-1572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-26
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036-0347-H315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11-1714OtherMEDICARE PTAN