Basic Information
| Provider Information | |||||||||
| NPI: | 1760434914 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GGNSC TUCKER BRIARWOOD LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GOLDEN LIVINGCENTER - BRIARWOOD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3888 LAVISTA RD | ||||||||
| Address2: | |||||||||
| City: | TUCKER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300845142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709385740 | ||||||||
| FaxNumber: | 7709082803 | ||||||||
| Practice Location | |||||||||
| Address1: | 3888 LAVISTA RD | ||||||||
| Address2: | |||||||||
| City: | TUCKER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300845142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709385740 | ||||||||
| FaxNumber: | 7709082803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 07/03/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RASMUSSEN-JONES | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4792014835 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GGNSC EQUITY HOLDINGS LLC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1-044-1858 | GA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00706813A | 05 | GA | MEDICAID | 0523520 | 01 | GA | AETNA GA | OTHER | 4439532 | 01 | GA | AETNA GA | OTHER | 283969 | 01 | GA | WELLCARE HMO | OTHER | N220A | 01 | GA | KAISER GEORGIA | OTHER |