MEDICARE: FT GAINES HEALTHCARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility		GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124021506
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FT GAINES HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	101 HARTFORD RD
Second Line	:
City	:	FORT GAINES
State	:	GA
Zip	:	39851-3639
Country	:	US
Telephone Number	:	229-768-2521
Fax Number	:	229-768-2466

Provider Business Practice Location Address
First Line	:	101 HARTFORD RD
Second Line	:
City	:	FORT GAINES
State	:	GA
Zip	:	39851-3639
Country	:	US
Telephone Number	:	229-768-2521
Fax Number	:	229-768-2466

Authorized Official
Title or Position	:	MANAGER
Name	:	TYGH BROGDON
Credential	:
Telephone Number	:	770-650-8773

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	09/29/2008

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