Healthcare Provider Details

I. General information

NPI: 1548791429
Provider Name (Legal Business Name): CPLACE CHATSWORTH SNF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 HOSPITAL DR
CHATSWORTH GA
30705-2058
US

IV. Provider business mailing address

24641 US HIGHWAY 19 N
CLEARWATER FL
33763-5007
US

V. Phone/Fax

Practice location:
  • Phone: 706-695-8313
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1-105-1014
License Number StateGA

VIII. Authorized Official

Name: VICTOR M MARCOS
Title or Position: CFO
Credential:
Phone: 917-209-1431