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NPI Code Detail

MEDICARE: COUNTRY MANOR ESTATES PERSONAL CARE HOME LLC

MEDICARE: COUNTRY MANOR ESTATES PERSONAL CARE HOME LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1310400000XAssisted Living Facility011-01-058-1GA

General Provider Information

NPI Number : 1851692008
Entity Type Code : Organization
Provider Name (Legal Business Name) : COUNTRY MANOR ESTATES PERSONAL CARE HOME LLC
Provider Business Mailing Address
First Line : 1487 ALLEN RD
Second Line :
City : MACON
State : GA
Zip : 31216-5817
Country : US
Telephone Number : 478-781-9387
Fax Number : 478-781-9387
Provider Business Practice Location Address
First Line : 1487 ALLEN RD
Second Line :
City : MACON
State : GA
Zip : 31216-5817
Country : US
Telephone Number : 478-781-9387
Fax Number : 478-781-9387
Authorized Official
Title or Position : OWNER
Name : MS. FAYE L GROOVER
Credential :
Telephone Number : 478-781-9387
Provider Enumeration Date : 11/04/2010
Last Update Date : 11/04/2010

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Directions to “COUNTRY MANOR ESTATES PERSONAL CARE HOME LLC ” Practice Location

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