1659307700 NPI number — TREUTLEN COUNTY NURSING HOME LLC

Table of content: (NPI 1659307700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659307700 NPI number — TREUTLEN COUNTY NURSING HOME LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TREUTLEN COUNTY NURSING HOME 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:
Provider Other Organization Name Type Code:
6
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:
1659307700
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 408
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOPERTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30457-0408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-529-4418
Provider Business Mailing Address Fax Number:
912-529-3322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2249 COLLEGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOPERTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30457-3627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-529-4418
Provider Business Practice Location Address Fax Number:
912-529-3322
Provider Enumeration Date:
06/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PEAVY
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
912-529-4418

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  1-140-1782 , 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: 000143349A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51001081 001 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com