MEDICARE: RANDOLPH GARDENS SNF OPERATIONS 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
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1932929403
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDOLPH GARDENS SNF OPERATIONS LLC

Provider Business Mailing Address
First Line	:	4801 RANDOLPH RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-2921
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4801 RANDOLPH RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-2921
Country	:	US
Telephone Number	:	704-364-8363
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT OF PROCUREMENT
Name	:	JOSEPH LIEBERMAN
Credential	:
Telephone Number	:	646-275-4510

Provider Enumeration Date	:	10/10/2024
Last Update Date	:	10/10/2024

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