Healthcare Provider Details

I. General information

NPI: 1023044518
Provider Name (Legal Business Name): BULLOCH COUNTY LTC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 S COLLEGE ST
STATESBORO GA
30458-5409
US

IV. Provider business mailing address

PO BOX 746
STATESBORO GA
30459-0746
US

V. Phone/Fax

Practice location:
  • Phone: 912-764-4575
  • Fax: 912-764-3916
Mailing address:
  • Phone: 912-764-4575
  • Fax: 912-764-3916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1-016-1898
License Number StateGA

VIII. Authorized Official

Name: TAYLOR MCCOY
Title or Position: ADMINISTRATOR
Credential:
Phone: 912-764-4575