Provider Demographics
NPI:1093987232
Name:FORT VALLEY OPERATOR LLC
Entity Type:Organization
Organization Name:FORT VALLEY OPERATOR LLC
Other - Org Name:FORT VALLEY HEALTH AND REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DELKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-321-1239
Mailing Address - Street 1:604 BLUEBIRD BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-5081
Mailing Address - Country:US
Mailing Address - Phone:478-825-2031
Mailing Address - Fax:478-825-2041
Practice Address - Street 1:604 BLUEBIRD BLVD
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-5081
Practice Address - Country:US
Practice Address - Phone:478-825-2031
Practice Address - Fax:478-825-2041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-111-1073314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000141028AMedicaid
115651Medicare Oscar/Certification