MEDICARE: COUNTRY MANOR ESTATES PERSONAL CARE HOME 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	310400000X	Assisted Living Facility	011-01-058-1	GA

General Provider Information

NPI Number	:	1851692008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRY MANOR ESTATES PERSONAL CARE HOME LLC

Provider Business Mailing Address
First Line	:	1487 ALLEN RD
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31216-5817
Country	:	US
Telephone Number	:	478-781-9387
Fax Number	:	478-781-9387

Provider Business Practice Location Address
First Line	:	1487 ALLEN RD
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31216-5817
Country	:	US
Telephone Number	:	478-781-9387
Fax Number	:	478-781-9387

Authorized Official
Title or Position	:	OWNER
Name	:	MS. FAYE L GROOVER
Credential	:
Telephone Number	:	478-781-9387

Provider Enumeration Date	:	11/04/2010
Last Update Date	:	11/04/2010

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