Healthcare Provider Details

I. General information

NPI: 1114121845
Provider Name (Legal Business Name): LAKE OCONEE ASSISTED LIVING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 WILSON ST
GREENSBORO GA
30642-1426
US

IV. Provider business mailing address

PO BOX 1152 105 WILSON STREET
GREENSBORO GA
30642-8152
US

V. Phone/Fax

Practice location:
  • Phone: 706-453-7155
  • Fax: 706-453-4156
Mailing address:
  • Phone: 706-453-7155
  • Fax: 706-453-4156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: LILLIE R TRIPP
Title or Position: OWNER
Credential:
Phone: 706-453-9055