Provider Demographics
NPI:1053312736
Name:MEADOWBROOK NURSING HOME INC
Entity Type:Organization
Organization Name:MEADOWBROOK NURSING HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:PENLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-855-1773
Mailing Address - Street 1:4608 LAWRENCEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-2903
Mailing Address - Country:US
Mailing Address - Phone:770-938-0118
Mailing Address - Fax:770-491-8760
Practice Address - Street 1:4608 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-2903
Practice Address - Country:US
Practice Address - Phone:770-938-0118
Practice Address - Fax:770-491-8760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00141864AMedicaid
1054670001OtherDME#
11 5561Medicare ID - Type Unspecified