Healthcare Provider Details

I. General information

NPI: 1053300566
Provider Name (Legal Business Name): BAYVIEW NURSING HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 04/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12884 CLEVELAND ST W
NAHUNTA GA
31553-2834
US

IV. Provider business mailing address

1211 MACON RD STE D
PERRY GA
31069-2679
US

V. Phone/Fax

Practice location:
  • Phone: 912-462-6044
  • Fax: 912-462-6686
Mailing address:
  • Phone: 478-988-1294
  • Fax: 478-988-1193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number10131392
License Number StateGA

VII. Legacy identifiers

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

# 1
Identifier000624951B
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 2
Identifier000624951A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: MR. WILLIAM C. DAVIS JR.
Title or Position: PRESIDENT
Credential:
Phone: 478-988-1294