Healthcare Provider Details

I. General information

NPI: 1710965033
Provider Name (Legal Business Name): DOUGLASVILLE NURSING AND REHABILITATION CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4028 HIGHWAY 5
DOUGLASVILLE GA
30135-3530
US

IV. Provider business mailing address

P O BOX 0428
ORCHARD PARK NY
14127
US

V. Phone/Fax

Practice location:
  • Phone: 770-942-7111
  • Fax: 770-489-1268
Mailing address:
  • Phone: 716-662-4955
  • Fax: 716-667-9230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1-048-1741
License Number StateGA

VIII. Authorized Official

Name: MR. NORBERT A BENNETT
Title or Position: CO CHIEF EXECUTIVE OFFICER
Credential:
Phone: 716-662-4955