Healthcare Provider Details

I. General information

NPI: 1124021506
Provider Name (Legal Business Name): FT GAINES HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 09/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HARTFORD RD
FORT GAINES GA
39851-3639
US

IV. Provider business mailing address

101 HARTFORD RD
FORT GAINES GA
39851-3639
US

V. Phone/Fax

Practice location:
  • Phone: 229-768-2521
  • Fax: 229-768-2466
Mailing address:
  • Phone: 229-768-2521
  • Fax: 229-768-2466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TYGH BROGDON
Title or Position: MANAGER
Credential:
Phone: 770-650-8773