MEDICARE: LC SNF, 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	:	1619378593
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LC SNF, LLC

Provider Business Mailing Address
First Line	:	93 HIGHWAY 19
Second Line	:
City	:	LUMBER CITY
State	:	GA
Zip	:	31549-2556
Country	:	US
Telephone Number	:	912-363-2484
Fax Number	:	912-363-8182

Provider Business Practice Location Address
First Line	:	93 HIGHWAY 19
Second Line	:
City	:	LUMBER CITY
State	:	GA
Zip	:	31549-2556
Country	:	US
Telephone Number	:	912-363-2484
Fax Number	:	912-363-8182

Authorized Official
Title or Position	:	MANAGER
Name	:	BRUCE E WERTHEIM
Credential	:
Telephone Number	:	917-919-7204

Provider Enumeration Date	:	09/10/2014
Last Update Date	:	01/19/2022

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