Healthcare Provider Details

I. General information

NPI: 1871589580
Provider Name (Legal Business Name): CHRISTIAN CITY CONVALESCENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 LESTER RD
UNION CITY GA
30291-2328
US

IV. Provider business mailing address

7300 LESTER RD
UNION CITY GA
30291-2328
US

V. Phone/Fax

Practice location:
  • Phone: 770-964-3301
  • Fax:
Mailing address:
  • Phone: 770-964-3301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNHA004005
License Number StateGA

VIII. Authorized Official

Name: MR. BRUCE R. ERICKSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 770-703-2611