1467742858 NPI number — G.R. JACKSON SENIOR CARE

Table of content: (NPI 1467742858)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467742858 NPI number — G.R. JACKSON SENIOR CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
G.R. JACKSON SENIOR CARE
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:
1467742858
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1325 SIX FLAGS DR
Provider Second Line Business Mailing Address:
#1207
Provider Business Mailing Address City Name:
AUSTELL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30168-7065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-274-4498
Provider Business Mailing Address Fax Number:
678-324-6791

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1325 SIX FLAGS DR
Provider Second Line Business Practice Location Address:
#1207
Provider Business Practice Location Address City Name:
AUSTELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30168-7065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-274-4498
Provider Business Practice Location Address Fax Number:
678-324-6791
Provider Enumeration Date:
04/19/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TAFIE
Authorized Official First Name:
ORTEASA
Authorized Official Middle Name:
MARIA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
404-274-4498

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  CN0028902879 , 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)