Healthcare Provider Details

I. General information

NPI: 1639103690
Provider Name (Legal Business Name): PLACE AT AUGUSTA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 06/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 STEVENS CREEK RD
AUGUSTA GA
30907-9251
US

IV. Provider business mailing address

820 STEVENS CREEK RD
AUGUSTA GA
30907-9251
US

V. Phone/Fax

Practice location:
  • Phone: 615-706-8606
  • Fax:
Mailing address:
  • Phone: 706-860-6622
  • Fax: 706-860-6532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000213463A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: W MELISSA ODEN
Title or Position: OWNER
Credential:
Phone: 615-585-4444