Healthcare Provider Details

I. General information

NPI: 1982628491
Provider Name (Legal Business Name): MONTEZUMA HEALTH CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 SUMTER ST
MONTEZUMA GA
31063-1734
US

IV. Provider business mailing address

PO BOX 639
MONTEZUMA GA
31063-0639
US

V. Phone/Fax

Practice location:
  • Phone: 478-472-8168
  • Fax: 478-472-2373
Mailing address:
  • Phone: 478-472-8168
  • Fax: 478-472-2373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number1-094-1731
License Number StateGA

VIII. Authorized Official

Name: JACKIE CRISP
Title or Position: ADMINISTRATOR
Credential:
Phone: 478-472-8168