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General NPI Number Information
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NPI Number | 1700888740
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Entity Type | Organization
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Legal Business Name | LTC HEALTHCARE OF STATESBORO INC
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Dates
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Enumeration Date | 08/10/2005
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Last Update Date | 07/18/2019
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Provider Practice Location Address
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Address Line | 101 STOCKYARD RD
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City | STATESBORO
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State | GA
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Zip | 30458-1343
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Country | US
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Telephone | 912-764-6005
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Fax | 912-764-4099
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Provider Business Mailing Address
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Address Line | 995 CANTON ST STE 100
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City | ROSWELL
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State | GA
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Zip | 30075-4240
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Country | US
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Telephone | 770-993-4000
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ROBERT HAGAN
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Credential |
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Telephone | 770-993-4000
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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 |
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License Number State |
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