MEDICARE: BLECKLEY NH, 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	1-012-2016	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	:	1669817797
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLECKLEY NH, LLC

Provider Business Mailing Address
First Line	:	601 6TH ST SE
Second Line	:
City	:	COCHRAN
State	:	GA
Zip	:	31014-9534
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 6TH ST SE
Second Line	:
City	:	COCHRAN
State	:	GA
Zip	:	31014-9534
Country	:	US
Telephone Number	:	478-934-7682
Fax Number	:

Authorized Official
Title or Position	:	SECRETARY
Name	:	NANCY SHMAYS
Credential	:
Telephone Number	:	770-650-7086

Provider Enumeration Date	:	05/02/2013
Last Update Date	:	09/27/2013

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Directions to “BLECKLEY NH, LLC ” Practice Location

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