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General NPI Number Information
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NPI Number | 1992068670
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Entity Type | Organization
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Legal Business Name | EDGEWOOD OF MONTICELLO
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Dates
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Enumeration Date | 06/19/2012
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Last Update Date | 06/19/2012
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Provider Practice Location Address
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Address Line | 1178 COLLEGE ST
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City | MONTICELLO
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State | GA
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Zip | 31064-2111
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Country | US
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Telephone | 706-468-7100
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Fax | 706-468-7090
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Provider Business Mailing Address
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Address Line | 1178 COLLEGE ST
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City | MONTICELLO
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State | GA
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Zip | 31064-2111
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Country | US
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Telephone | 706-468-7100
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Fax | 706-468-7090
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MS. ANNA D. MARLOW
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Credential |
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Telephone | 706-468-7100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 079020011
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License Number State | GA
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