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General NPI Number Information
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NPI Number | 1114121845
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Entity Type | Organization
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Legal Business Name | LAKE OCONEE ASSISTED LIVING HOME
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Dates
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Enumeration Date | 06/14/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 105 WILSON ST
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City | GREENSBORO
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State | GA
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Zip | 30642-1426
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Country | US
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Telephone | 706-453-7155
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Fax | 706-453-4156
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Provider Business Mailing Address
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Address Line | PO BOX 1152 105 WILSON STREET
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City | GREENSBORO
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State | GA
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Zip | 30642-8152
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Country | US
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Telephone | 706-453-7155
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Fax | 706-453-4156
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Authorized Official
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Title or Position | OWNER
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Name | LILLIE R TRIPP
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Credential |
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Telephone | 706-453-9055
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0630X
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Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
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License Number |
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License Number State |
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