Healthcare Provider Details

I. General information

NPI: 1114375698
Provider Name (Legal Business Name): BN SNF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2016
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 S COLLEGE ST
STATESBORO GA
30458-5299
US

IV. Provider business mailing address

226 S COLLEGE ST
STATESBORO GA
30458-5299
US

V. Phone/Fax

Practice location:
  • Phone: 912-764-9631
  • Fax: 912-764-8384
Mailing address:
  • Phone: 912-764-9631
  • Fax: 912-764-8384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BRUCE E WERTHEIM
Title or Position: MANAGER
Credential:
Phone: 813-347-9888