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General NPI Number Information
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NPI Number | 1902296866
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Entity Type | Organization
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Legal Business Name | IRIS COVE PERSONAL CARE HOME
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Dates
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Enumeration Date | 01/30/2015
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Last Update Date | 01/30/2015
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Provider Practice Location Address
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Address Line | 2382 WHEELESS RD
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City | AUGUSTA
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State | GA
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Zip | 30906-5404
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Country | US
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Telephone | 706-723-5949
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Fax |
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Provider Business Mailing Address
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Address Line | 2382 WHEELESS RD
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City | AUGUSTA
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State | GA
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Zip | 30906-5404
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Country | US
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Telephone | 706-723-5949
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | NICOLE BENTLEY
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Credential |
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Telephone | 706-306-0273
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311Z00000X
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Taxonomy Name | Custodial Care Facility
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License Number | LCB20130000967
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License Number State | GA
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