Healthcare Provider Details

I. General information

NPI: 1770755951
Provider Name (Legal Business Name): ROBERTA OPERATOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 MYRTLE DR
ROBERTA GA
31078-9752
US

IV. Provider business mailing address

420 MYRTLE DR
ROBERTA GA
31078-9752
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 Number1-039-1080
License Number StateGA

VIII. Authorized Official

Name: DAVID THORNTON
Title or Position: ADMINISTRATOR
Credential:
Phone: 478-836-3101