1578841029 NPI number — OLIVE GARDEN HEALTHCARE SERV. LLC

Table of content: (NPI 1578841029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578841029 NPI number — OLIVE GARDEN HEALTHCARE SERV. LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OLIVE GARDEN HEALTHCARE SERV. 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:
Provider Other Organization Name Type Code:
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:
1578841029
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1231 SWEETGUM TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONYERS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30012-3593
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
90 COMMERCE DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214-7519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-256-5005
Provider Business Practice Location Address Fax Number:
404-889-8661
Provider Enumeration Date:
08/02/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BOLAJI
Authorized Official First Name:
DORCAS
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
678-907-2089

Provider Taxonomy Codes

  • Taxonomy code: 251J00000X , with the licence number:  O56-R-0865 , 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)





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