1417904079 NPI number — BRYANT HEALTH AND REHABILITATION CENTER, INC.

Table of content: (NPI 1417904079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417904079 NPI number — BRYANT HEALTH AND REHABILITATION CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRYANT HEALTH AND REHABILITATION CENTER, INC.
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:
1417904079
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 476
Provider Second Line Business Mailing Address:
601 6TH ST.
Provider Business Mailing Address City Name:
COCHRAN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31014-0476
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-934-7682
Provider Business Mailing Address Fax Number:
478-937-1558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 6TH ST SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COCHRAN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31014-1433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-934-7682
Provider Business Practice Location Address Fax Number:
478-937-1558
Provider Enumeration Date:
05/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FALLAW
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
229-268-7510

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  1-012-1867 , 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: 51001233001 . This is a "BLUE CROSS/BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00142601A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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