1801978499 NPI number — FORUM GROUP AT WILDWOOD PARK NURSING & REHABILITATION CENTER, LLC

Table of content: (NPI 1801978499)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801978499 NPI number — FORUM GROUP AT WILDWOOD PARK NURSING & REHABILITATION CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORUM GROUP AT WILDWOOD PARK NURSING & REHABILITATION CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
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Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
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Provider Other Last Name:
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NPI Number Information

NPI Number:
1801978499
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:
1700 WATER PL SE
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30339-2006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-213-2700
Provider Business Mailing Address Fax Number:
678-213-2705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2611 WILDWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31520-4250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-264-1434
Provider Business Practice Location Address Fax Number:
912-466-9604
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOUSER
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
DALYN
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
706-291-8600

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  10631819 , 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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