Provider Demographics
NPI:1275520751
Name:BRIGHTMOOR HOSPICE, LLC
Entity Type:Organization
Organization Name:BRIGHTMOOR HOSPICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-972-1642
Mailing Address - Street 1:3247 NEWNAN RD
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-7114
Mailing Address - Country:US
Mailing Address - Phone:770-467-9930
Mailing Address - Fax:770-467-9932
Practice Address - Street 1:3247 NEWNAN RD
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-7114
Practice Address - Country:US
Practice Address - Phone:770-467-9930
Practice Address - Fax:770-467-9932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA111618251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000140412BMedicaid