Provider Demographics
NPI:1053314039
Name:MIDDLE GEORGIA NURSING HOME, INC
Entity Type:Organization
Organization Name:MIDDLE GEORGIA NURSING HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARVILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-374-0805
Mailing Address - Street 1:556 CHESTER HWY
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-3717
Mailing Address - Country:US
Mailing Address - Phone:478-374-4733
Mailing Address - Fax:478-374-1688
Practice Address - Street 1:556 CHESTER HWY
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-3717
Practice Address - Country:US
Practice Address - Phone:478-374-4733
Practice Address - Fax:478-374-1688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2008-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10451407314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0001419174AMedicaid
3725960001Medicare NSC
GA0001419174AMedicaid