Healthcare Provider Details

I. General information

NPI: 1962251645
Provider Name (Legal Business Name): PHG MCRAE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 S FIRST AVE
MC RAE GA
31055-3334
US

IV. Provider business mailing address

160 S FIRST AVE
MC RAE GA
31055-3334
US

V. Phone/Fax

Practice location:
  • Phone: 229-868-6473
  • Fax: 229-868-2981
Mailing address:
  • Phone: 229-868-6473
  • Fax: 229-868-2981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: DAVID LEMCKE
Title or Position: MEMBER
Credential:
Phone: 678-808-4071