Healthcare Provider Details

I. General information

NPI: 1487276184
Provider Name (Legal Business Name): 1115 SMITH OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 MARKET ST
THOMASVILLE GA
31792-5782
US

IV. Provider business mailing address

3630 ILLINOIS RD
FORT WAYNE IN
46804-2062
US

V. Phone/Fax

Practice location:
  • Phone: 229-222-9155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: RYAN PERSON
Title or Position: DIRECTOR OF BUSINESS DEVELOPMENT
Credential:
Phone: 260-413-4159