MEDICARE: CHRISTIAN CITY CONVALESCENT CENTER

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	NHA004005	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	71-00122	OTHER	GA	EVERCARE/UNITED HEALTH CA

General Provider Information

NPI Number	:	1871589580
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRISTIAN CITY CONVALESCENT CENTER

Provider Business Mailing Address
First Line	:	7300 LESTER RD
Second Line	:
City	:	UNION CITY
State	:	GA
Zip	:	30291-2328
Country	:	US
Telephone Number	:	770-964-3301
Fax Number	:

Provider Business Practice Location Address
First Line	:	7300 LESTER RD
Second Line	:
City	:	UNION CITY
State	:	GA
Zip	:	30291-2328
Country	:	US
Telephone Number	:	770-964-3301
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. BRUCE R. ERICKSON
Credential	:
Telephone Number	:	770-703-2611

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	08/22/2020

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