Healthcare Provider Details

I. General information

NPI: 1346526134
Provider Name (Legal Business Name): FIRESIDE-LTC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2011
Last Update Date: 11/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 MARTIN LUTHER KING DR
CENTRALIA IL
62801-3002
US

IV. Provider business mailing address

10945 STATE BRIDGE RD SUITE 401-470
ALPHARETTA GA
30022-8164
US

V. Phone/Fax

Practice location:
  • Phone: 678-522-2436
  • Fax: 770-663-4539
Mailing address:
  • Phone: 678-522-2436
  • Fax: 770-663-4539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. DAREN G DOUSTON
Title or Position: MEMBER CFO
Credential:
Phone: 678-522-2436