Healthcare Provider Details

I. General information

NPI: 1194917617
Provider Name (Legal Business Name): LAKE OCONEE ASSISTED LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E BROAD ST
GREENSBORO GA
30642-1337
US

IV. Provider business mailing address

107 E BROAD ST P.O. BOX 1152
GREENSBORO GA
30642-1337
US

V. Phone/Fax

Practice location:
  • Phone: 706-453-9055
  • Fax: 706-453-4156
Mailing address:
  • Phone: 706-453-9055
  • Fax: 706-453-4156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License NumberCLA001142
License Number StateGA

VIII. Authorized Official

Name: LILLIE R. TRIPP
Title or Position: CONTROLLING MANAGER
Credential:
Phone: 706-453-9055