MEDICARE: LYNCHBURG 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

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	:	1639652944
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LYNCHBURG HEALTHCARE, LLC

Provider Business Mailing Address
First Line	:	3050 ROYAL BLVD S STE 190
Second Line	:
City	:	ALPHARETTA
State	:	GA
Zip	:	30022-1417
Country	:	US
Telephone Number	:	470-282-3268
Fax Number	:	470-268-7957

Provider Business Practice Location Address
First Line	:	2406 ATHERHOLT RD
Second Line	:
City	:	LYNCHBURG
State	:	VA
Zip	:	24501-2148
Country	:	US
Telephone Number	:	434-846-3200
Fax Number	:	434-846-3436

Authorized Official
Title or Position	:	PRESIDENT OF MANAGING MEMBER
Name	:	DOUG MITTLEIDER
Credential	:
Telephone Number	:	470-282-3271

Provider Enumeration Date	:	09/12/2018
Last Update Date	:	09/12/2018

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