Healthcare Provider Details

I. General information

NPI: 1053463786
Provider Name (Legal Business Name): ADK JEFFERSONVILLE OPERATOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 SPRING VALLEY DRIVE
JEFFERSONVILLE GA
31044-9301
US

IV. Provider business mailing address

113 SPRING VALLEY DRIVE
JEFFERSONVILLE GA
31044-9301
US

V. Phone/Fax

Practice location:
  • Phone: 478-945-2520
  • Fax: 478-945-2525
Mailing address:
  • Phone: 478-945-2520
  • Fax: 478-945-2525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number11431882
License Number StateGA

VIII. Authorized Official

Name: CAROL GROEBER
Title or Position: VP MIS
Credential:
Phone: 937-964-8974