1265463004 NPI number — HOSPITAL AUTHORITY OF LIBERTY COUNTY

Table of content: (NPI 1265463004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265463004 NPI number — HOSPITAL AUTHORITY OF LIBERTY COUNTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOSPITAL AUTHORITY OF LIBERTY COUNTY
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:
COASTAL MANOR NURSING HOME
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:
1265463004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
RR 3 BOX 2D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUDOWICI
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31316-9701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-545-3392
Provider Business Mailing Address Fax Number:
912-545-9588

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HWY 84 EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUDOWICI
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-545-3392
Provider Business Practice Location Address Fax Number:
912-545-9588
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROZIER
Authorized Official First Name:
DEREK
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
912-369-9427

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , 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)

  • Identifier: 000856028A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com