Provider Demographics
NPI:1083024608
Name:MCTWYNN, INC
Entity Type:Organization
Organization Name:MCTWYNN, INC
Other - Org Name:LAKEVIEW RETIREMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:V.P./SEC
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:JENKINS
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-367-9109
Mailing Address - Street 1:426 E. PARKER ST
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513
Mailing Address - Country:US
Mailing Address - Phone:912-367-9109
Mailing Address - Fax:912-367-5927
Practice Address - Street 1:111 STEPHENS AVE
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513
Practice Address - Country:US
Practice Address - Phone:912-367-9109
Practice Address - Fax:912-367-5927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPERMIT NO PCH009056310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility