Healthcare Provider Details

I. General information

NPI: 1760879332
Provider Name (Legal Business Name): BRISTOL VILLAGE MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2015
Last Update Date: 04/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1358 MANCHESTER DR NE
CONYERS GA
30012-3881
US

IV. Provider business mailing address

1358 MANCHESTER DR NE
CONYERS GA
30012-3881
US

V. Phone/Fax

Practice location:
  • Phone: 470-207-7250
  • Fax: 470-207-7249
Mailing address:
  • Phone: 470-207-7250
  • Fax: 470-207-7249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. MATTHEW STEPHEN
Title or Position: ADMINISTRATOR
Credential:
Phone: 470-207-7250