Healthcare Provider Details

I. General information

NPI: 1669817797
Provider Name (Legal Business Name): BLECKLEY NH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 6TH ST SE
COCHRAN GA
31014-9534
US

IV. Provider business mailing address

601 6TH ST SE
COCHRAN GA
31014-9534
US

V. Phone/Fax

Practice location:
  • Phone: 478-934-7682
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1-012-2016
License Number StateGA

VII. Legacy identifiers

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

# 1
Identifier000142601A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: NANCY SHMAYS
Title or Position: SECRETARY
Credential:
Phone: 770-650-7086