Provider Demographics
NPI:1053492801
Name:ADK BONTERRA PARKVIEW, LLC
Entity Type:Organization
Organization Name:ADK BONTERRA PARKVIEW, LLC
Other - Org Name:BONTERRA NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT MIS
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:J
Authorized Official - Last Name:GROEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-964-8974
Mailing Address - Street 1:2801 FELTON DR
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-3605
Mailing Address - Country:US
Mailing Address - Phone:404-767-7591
Mailing Address - Fax:404-765-0547
Practice Address - Street 1:2801 FELTON DR
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3605
Practice Address - Country:US
Practice Address - Phone:404-767-7591
Practice Address - Fax:404-765-0547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10777314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000140357AMedicaid
GA115555Medicare ID - Type Unspecified