Provider Demographics
NPI:1114181161
Name:SOUTH DOOLEY RETIREMENT CENTER
Entity Type:Organization
Organization Name:SOUTH DOOLEY RETIREMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:ELLIS
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:478-783-4117
Mailing Address - Street 1:105 SOUTH DOOLEY STREET
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036
Mailing Address - Country:US
Mailing Address - Phone:478-783-4117
Mailing Address - Fax:
Practice Address - Street 1:105 S DOOLEY ST
Practice Address - Street 2:105 SOUTH DOOLEY STREET
Practice Address - City:HAWKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31036-1703
Practice Address - Country:US
Practice Address - Phone:478-783-4117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA968169651AMedicaid
GA968169651BMedicaid