=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225701667
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIGHTMOOR NURSING CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2021
-----------------------------------------------------
Last Update Date | 05/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3235 NEWNAN RD
-----------------------------------------------------
City | GRIFFIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30223-7114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-228-8599
-----------------------------------------------------
Fax | 770-228-6618
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3247 NEWNAN RD
-----------------------------------------------------
City | GRIFFIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30223-7114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-972-1644
-----------------------------------------------------
Fax | 770-467-9932
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATIONS OFFICER
-----------------------------------------------------
Name | MR. HOWARD WATSON REESE III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-972-1644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------