=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831227347
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHNSON COUNTY NURSING HOME, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 SCHOOL ST
-----------------------------------------------------
City | ADRIAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-668-3225
-----------------------------------------------------
Fax | 478-668-3927
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 287
-----------------------------------------------------
City | ADRIAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31002-0287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-668-3225
-----------------------------------------------------
Fax | 478-668-3927
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF FINANCIAL REPORTING
-----------------------------------------------------
Name | KIM SHEFFIELD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 478-621-2100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number | 1-083-1775
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------