Provider Demographics
NPI:1083776520
Name:BRENTWOOD NURSING LLC
Entity Type:Organization
Organization Name:BRENTWOOD NURSING LLC
Other - Org Name:ROBERTA HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TYGH
Authorized Official - Middle Name:
Authorized Official - Last Name:BROGDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-650-8773
Mailing Address - Street 1:280 MYRTLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROBERTA
Mailing Address - State:GA
Mailing Address - Zip Code:31078
Mailing Address - Country:US
Mailing Address - Phone:478-836-3101
Mailing Address - Fax:478-836-2700
Practice Address - Street 1:280 MYRTLE DRIVE
Practice Address - Street 2:
Practice Address - City:ROBERTA
Practice Address - State:GA
Practice Address - Zip Code:31078
Practice Address - Country:US
Practice Address - Phone:478-836-3101
Practice Address - Fax:478-836-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-039-1747314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00142777AMedicaid
GA11-5523Medicare ID - Type UnspecifiedMEDICARE NUMBER