Healthcare Provider Details

I. General information

NPI: 1255327862
Provider Name (Legal Business Name): DELMAR GARDENS OF GWINNETT OPERATING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 CLUB DR
LAWRENCEVILLE GA
30044-2591
US

IV. Provider business mailing address

14805 N OUTER 40 RD SUITE 300
CHESTERFIELD MO
63017-6060
US

V. Phone/Fax

Practice location:
  • Phone: 770-923-3100
  • Fax: 770-381-5422
Mailing address:
  • Phone: 636-733-7000
  • Fax: 636-733-7010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1-067-1829
License Number StateGA

VIII. Authorized Official

Name: MR. GAIL LEE HARTMANN
Title or Position: TREASURER
Credential:
Phone: 636-733-7000