Provider Demographics
NPI:1265463004
Name:HOSPITAL AUTHORITY OF LIBERTY COUNTY
Entity Type:Organization
Organization Name:HOSPITAL AUTHORITY OF LIBERTY COUNTY
Other - Org Name:COASTAL MANOR NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROZIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-369-9427
Mailing Address - Street 1:RR 3 BOX 2D
Mailing Address - Street 2:
Mailing Address - City:LUDOWICI
Mailing Address - State:GA
Mailing Address - Zip Code:31316-9701
Mailing Address - Country:US
Mailing Address - Phone:912-545-3392
Mailing Address - Fax:912-545-9588
Practice Address - Street 1:HWY 84 EAST
Practice Address - Street 2:
Practice Address - City:LUDOWICI
Practice Address - State:GA
Practice Address - Zip Code:31316
Practice Address - Country:US
Practice Address - Phone:912-545-3392
Practice Address - Fax:912-545-9588
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOSPITAL AUTHORITY OF LIBERTY COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000856028AMedicaid
GA115665Medicare ID - Type Unspecified