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Organization Active NPI

TMC/Villa Rica Hospital, Inc

  • Psychiatric Hospital Unit
  • Villa Rica, GA
National Provider Identifier
1104066265
Registry record updated Jul 28, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric Hospital UnitTaxonomy code 273R00000X
Legal business name
TMC/VILLA RICA HOSPITAL, INC
Practice address
601 Dallas Hwy
Villa Rica, GA 30180-1202
Phone
(770) 456-3000
Fax
(770) 456-3390
NPI assigned
Mar 3, 2009
Organization subpart
Yes
Parent organization
TMC/VILLA RICA HOSPITAL, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 28, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Lee C. Sherseth
Title
Cfo
Phone
(770) 836-9697

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric Hospital Unit 273R00000X Primary

Addresses

Primary practice location

601 Dallas Hwy
Villa Rica, GA 30180-1202

Mailing address

PO Box 638
Villa Rica, GA 30180-0638
Phone (770) 836-9666

Other identifiers 1

IdentifierTypeStateIssuer
000002032AMedicaidGA

Other names 1

  • Willowbrooke at Tanner Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20090803000638 GA Part A Provider - Hospital 2961307533 Practice locations: Villa Rica, GA

Hospital certification: CCN 11S015

Legal name
TMC VILLA RICA HOSPITAL, INC
Organization structure
CorporationProprietary
Incorporated
Jul 1, 1988 in GA
Enrollment address
601 Dallas Hwy
Villa Rica, GA 30180-1202
Hospital Psychiatric Unit
Hospital subgroups
Psychiatric unit

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
TMC Villa Rica Hospital Inc3 organizations share this tax ID, including this one
Part of
TMC Villa Rica Hospital Inc

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Daniel Gordon Jackson Individual Corporate Director Apr 8, 2009
Carol Crews Individual Corporate OfficerCfo Feb 1, 2014
W-2 Managing Employee Feb 1, 2014
Anna Berry Individual Corporate Director Apr 15, 2022
Loy Howard Individual Corporate Officer Dec 11, 1994
Steve Ronnie Adams Individual Corporate Director Apr 8, 2009
Howard Ray Individual Corporate Director Apr 15, 2022
Tim Warren Individual Corporate Director Apr 15, 2022
Frederick O'Neal Individual Corporate Director Apr 15, 2022
Christopher Arant Individual Corporate Director Apr 15, 2022
Mary M. Covington Individual Corporate Director Apr 8, 2009
Lynne Clarke Individual Corporate Director Apr 15, 2022
Howard Jeffrey Lindsey Individual Corporate Director Apr 8, 2009
Gelon Wasdin Individual Corporate Director Apr 15, 2022

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1236038400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1280275200000",
    "number": "1104066265",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 638",
            "city": "VILLA RICA",
            "state": "GA",
            "postal_code": "301800638",
            "telephone_number": "770-836-9666",
            "fax_number": "770-456-3390"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "601 DALLAS HWY",
            "city": "VILLA RICA",
            "state": "GA",
            "postal_code": "301801202",
            "telephone_number": "770-456-3000",
            "fax_number": "770-456-3390"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TMC/VILLA RICA HOSPITAL, INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "TMC/VILLA RICA HOSPITAL, INC.",
        "enumeration_date": "2009-03-03",
        "last_updated": "2010-07-28",
        "status": "A",
        "authorized_official_last_name": "SHERSETH",
        "authorized_official_first_name": "LEE",
        "authorized_official_middle_name": "C.",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "770-836-9697",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "273R00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Unit",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000002032A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Willowbrooke at Tanner",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Villa Rica, GA

Sources for this page

Verify at the official NPI Registry.