Healthcare Provider Details

I. General information

NPI: 1407908163
Provider Name (Legal Business Name): ADK LAGRANGE OPERATOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 W POINT RD
LAGRANGE GA
30240-4047
US

IV. Provider business mailing address

2111 W POINT RD
LAGRANGE GA
30240-4047
US

V. Phone/Fax

Practice location:
  • Phone: 706-812-9293
  • Fax: 706-812-9353
Mailing address:
  • Phone: 706-812-9293
  • Fax: 706-812-9353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number11411885
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00270245A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

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