1053366336 NPI number — MT. KENN NURSING, LLC

Table of content: (NPI 1053366336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053366336 NPI number — MT. KENN NURSING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MT. KENN NURSING, 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:
AUTUMN BREEZE HEALTHCARE CENTER
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:
1053366336
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5057 TROY ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45502-8150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-964-8974
Provider Business Mailing Address Fax Number:
937-964-8961

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1480 SANDTOWN ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30008-3821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-442-1755
Provider Business Practice Location Address Fax Number:
770-442-8784
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GENTRY
Authorized Official First Name:
BOYD
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDNET AND CEO
Authorized Official Telephone Number:
937-964-8974

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  05-47025 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 1-033-1982 , 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: 00140159A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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