Provider Demographics
NPI:1083901706
Name:CHURCH HOME REHABILITATION AND HEALTHCARE, LLC
Entity Type:Organization
Organization Name:CHURCH HOME REHABILITATION AND HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, LTC ADM
Authorized Official - Phone:478-987-1239
Mailing Address - Street 1:PO BOX 1376
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-1376
Mailing Address - Country:US
Mailing Address - Phone:478-987-1239
Mailing Address - Fax:478-988-8273
Practice Address - Street 1:2470 HWY 41 NORTH
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030
Practice Address - Country:US
Practice Address - Phone:478-987-1239
Practice Address - Fax:478-988-8273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00140467A314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA115708Medicare Oscar/Certification