Provider Demographics
NPI:1861478851
Name:CLINCH COUNTY HOSPITAL AUTHORITY
Entity type:Organization
Organization Name:CLINCH COUNTY HOSPITAL AUTHORITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:P
Authorized Official - Last Name:AMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-487-5211
Mailing Address - Street 1:1050 VALDOSTA HWY
Mailing Address - Street 2:P.O. BOX 516
Mailing Address - City:HOMERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31634-2418
Mailing Address - Country:US
Mailing Address - Phone:912-487-5211
Mailing Address - Fax:912-487-4334
Practice Address - Street 1:1050 VALDOSTA HWY
Practice Address - Street 2:
Practice Address - City:HOMERVILLE
Practice Address - State:GA
Practice Address - Zip Code:31634-2418
Practice Address - Country:US
Practice Address - Phone:912-487-5211
Practice Address - Fax:912-487-4334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-21
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032-01341600000X
GA032-634282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00000415AMedicaid
GA00000415AMedicaid