Provider Demographics
NPI:1083966428
Name:TRULY LIVING WELL PCH, LLC
Entity Type:Organization
Organization Name:TRULY LIVING WELL PCH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CASEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-451-2890
Mailing Address - Street 1:326 RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-1954
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7078 BETHEL CT
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-2152
Practice Address - Country:US
Practice Address - Phone:678-519-4984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031011731310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility