Provider Demographics
NPI:1902120587
Name:SOUTHWEST GEORGIA REHAB, INC
Entity Type:Organization
Organization Name:SOUTHWEST GEORGIA REHAB, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HATHCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:229-273-9445
Mailing Address - Street 1:1107 GREER ST STE B
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-1921
Mailing Address - Country:US
Mailing Address - Phone:229-273-9445
Mailing Address - Fax:229-273-9447
Practice Address - Street 1:1107 GREER ST STE B
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-1921
Practice Address - Country:US
Practice Address - Phone:229-322-5880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005830225100000X
GA225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty