MEDICARE: CPLACE FAIRBURN 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	1-060-1010	GA

General Provider Information

NPI Number	:	1861923740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CPLACE FAIRBURN SNF LLC

Provider Business Mailing Address
First Line	:	24641 US HIGHWAY 19 N
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33763-5007
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	178 W CAMPBELLTON ST
Second Line	:
City	:	FAIRBURN
State	:	GA
Zip	:	30213-1219
Country	:	US
Telephone Number	:	770-964-1320
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	VICTOR M MARCOS
Credential	:
Telephone Number	:	917-209-1431

Provider Enumeration Date	:	03/23/2017
Last Update Date	:	03/23/2017

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