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General NPI Number Information
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NPI Number | 1053366336
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Entity Type | Organization
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Legal Business Name | MT. KENN NURSING, LLC
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Dates
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Enumeration Date | 05/24/2006
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Last Update Date | 07/25/2011
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Provider Practice Location Address
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Address Line | 1480 SANDTOWN ROAD
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City | MARIETTA
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State | GA
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Zip | 30008-3821
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Country | US
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Telephone | 770-442-1755
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Fax | 770-442-8784
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Provider Business Mailing Address
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Address Line | 5057 TROY ROAD
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City | SPRINGFIELD
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State | OH
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Zip | 45502-8150
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Country | US
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Telephone | 937-964-8974
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Fax | 937-964-8961
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Authorized Official
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Title or Position | PRESIDNET AND CEO
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Name | BOYD P GENTRY JR.
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Credential |
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Telephone | 937-964-8974
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 05-47025
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 1-033-1982
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License Number State | GA
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