Provider Demographics
NPI:1114118288
Name:LP MARIETTA LLC
Entity Type:Organization
Organization Name:LP MARIETTA LLC
Other - Org Name:SIGNATURE HEALTHCARE OF MARIETTA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-568-7800
Mailing Address - Street 1:811 KENNESAW AVE NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1002
Mailing Address - Country:US
Mailing Address - Phone:770-422-2451
Mailing Address - Fax:770-499-2235
Practice Address - Street 1:811 KENNESAW AVE NW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1002
Practice Address - Country:US
Practice Address - Phone:770-422-2451
Practice Address - Fax:770-499-2235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
6275480001Medicare NSC
GA115206Medicare Oscar/Certification