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NPI Code Detail

MEDICARE: PATRON PLACE LLC

MEDICARE: PATRON PLACE 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
1311Z00000XCustodial Care FacilityPCH006520GA
2311ZA0620XAdult Care Home FacilityPCH006520GA
3310400000XAssisted Living FacilityPCH006520GA

General Provider Information

NPI Number : 1457623308
Entity Type Code : Organization
Provider Name (Legal Business Name) : PATRON PLACE LLC
Provider Business Mailing Address
First Line : 1227 ROCKBRIDGE RD STE 208-196
Second Line :
City : STONE MOUNTAIN
State : GA
Zip : 30087-3064
Country : US
Telephone Number : 770-573-1076
Fax Number : 770-234-5894
Provider Business Practice Location Address
First Line : 1227 ROCKBRIDGE RD STE 208-196
Second Line :
City : STONE MOUNTAIN
State : GA
Zip : 30087-3064
Country : US
Telephone Number : 770-573-1076
Fax Number : 770-234-5894
Authorized Official
Title or Position : OWNER/ADMINISTRATOR
Name : MRS. RONDINE GORDON
Credential :
Telephone Number : 770-573-1076
Provider Enumeration Date : 02/07/2012
Last Update Date : 02/07/2012

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Directions to “PATRON PLACE LLC ” Practice Location

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