Provider Demographics
NPI:1114121845
Name:LAKE OCONEE ASSISTED LIVING HOME
Entity Type:Organization
Organization Name:LAKE OCONEE ASSISTED LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LILLIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:TRIPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-453-9055
Mailing Address - Street 1:PO BOX 1152
Mailing Address - Street 2:105 WILSON STREET
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30642-8152
Mailing Address - Country:US
Mailing Address - Phone:706-453-7155
Mailing Address - Fax:706-453-4156
Practice Address - Street 1:105 WILSON ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-1426
Practice Address - Country:US
Practice Address - Phone:706-453-7155
Practice Address - Fax:706-453-4156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherEFIN NUMBER