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General NPI Number Information
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NPI Number | 1992958474
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Entity Type | Organization
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Legal Business Name | SKYLAND MANOR PCH
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Dates
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Enumeration Date | 10/29/2008
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Last Update Date | 10/29/2008
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Provider Practice Location Address
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Address Line | 3505 SKYLAND DR
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City | LOGANVILLE
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State | GA
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Zip | 30052-8962
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Country | US
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Telephone | 770-985-3400
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Fax | 770-985-3425
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Provider Business Mailing Address
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Address Line | 22546 MURDOCK AVE
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City | QUEENS VILLAGE
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State | NY
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Zip | 11429-2729
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Country | US
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Telephone | 646-269-9764
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Fax | 718-465-1813
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Authorized Official
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Title or Position | MEMBER/MANAGER
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Name | MR. HUGH HENDERSON GREENIDGE
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Credential |
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Telephone | 646-269-9764
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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 | 061-01-329-1
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License Number State | GA
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