MEDICARE: TV THOMASVILLE 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

General Provider Information

NPI Number	:	1386355592
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TV THOMASVILLE LLC

Provider Business Mailing Address
First Line	:	120 SKYLINE DR
Second Line	:
City	:	THOMASVILLE
State	:	GA
Zip	:	31757-2507
Country	:	US
Telephone Number	:	229-225-1049
Fax Number	:	229-226-3128

Provider Business Practice Location Address
First Line	:	120 SKYLINE DR
Second Line	:
City	:	THOMASVILLE
State	:	GA
Zip	:	31757-2507
Country	:	US
Telephone Number	:	229-225-1049
Fax Number	:	229-226-3128

Authorized Official
Title or Position	:	MEMBER
Name	:	DAVID LEMCKE
Credential	:
Telephone Number	:	678-808-4071

Provider Enumeration Date	:	12/08/2022
Last Update Date	:	12/08/2022

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