Provider Demographics
NPI:1255327862
Name:DELMAR GARDENS OF GWINNETT OPERATING, LLC
Entity Type:Organization
Organization Name:DELMAR GARDENS OF GWINNETT OPERATING, LLC
Other - Org Name:DELMAR GARDENS OF GWINNETT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HARTMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-733-7000
Mailing Address - Street 1:14805 N OUTER 40 RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-6060
Mailing Address - Country:US
Mailing Address - Phone:636-733-7000
Mailing Address - Fax:636-733-7010
Practice Address - Street 1:3100 CLUB DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-2591
Practice Address - Country:US
Practice Address - Phone:770-923-3100
Practice Address - Fax:770-381-5422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-067-1829314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA156912785AMedicaid
115350Medicare Oscar/Certification