Healthcare Provider Details

I. General information

NPI: 1568631521
Provider Name (Legal Business Name): MARSH'S EDGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2008
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 RENEGAR WAY
SAINT SIMONS ISLAND GA
31522-8840
US

IV. Provider business mailing address

111 RENEGAR WAY
SAINT SIMONS ISLAND GA
31522-8840
US

V. Phone/Fax

Practice location:
  • Phone: 912-291-2038
  • Fax:
Mailing address:
  • Phone: 912-291-2038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. DONALD O. THOMPSON JR.
Title or Position: MANAGER
Credential:
Phone: 704-246-1616