1548397300 NPI number — BULLOCH COUNTY LTC, LLC

Table of content: (NPI 1548397300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548397300 NPI number — BULLOCH COUNTY LTC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BULLOCH COUNTY LTC, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EAGLE HEALTH & REHABILITATION
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548397300
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 746
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STATESBORO
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30459-0746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-764-4575
Provider Business Mailing Address Fax Number:
912-764-3916

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 S COLLEGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATESBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30458-5409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-764-4575
Provider Business Practice Location Address Fax Number:
912-764-3916
Provider Enumeration Date:
02/28/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHEFFIELD
Authorized Official First Name:
KIM
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF FINANCIAL REPORTING
Authorized Official Telephone Number:
478-621-2100

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X , with the licence number:  1-016-1802 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)