Healthcare Provider Details

I. General information

NPI: 1083776520
Provider Name (Legal Business Name): BRENTWOOD NURSING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 09/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 MYRTLE DRIVE
ROBERTA GA
31078
US

IV. Provider business mailing address

280 MYRTLE DRIVE
ROBERTA GA
31078
US

V. Phone/Fax

Practice location:
  • Phone: 478-836-3101
  • Fax: 478-836-2700
Mailing address:
  • Phone: 478-836-3101
  • Fax: 478-836-2700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1-039-1747
License Number StateGA

VIII. Authorized Official

Name: TYGH BROGDON
Title or Position: MANAGER
Credential:
Phone: 770-650-8773