Provider Demographics
NPI:1295374684
Name:WICKSHIRE BUFORD OPCO LLC
Entity Type:Organization
Organization Name:WICKSHIRE BUFORD OPCO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OKEEFE
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:615-942-0240
Mailing Address - Street 1:750 OLD HICKORY BLVD
Mailing Address - Street 2:BUILDING ONE SUITE 125
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027
Mailing Address - Country:US
Mailing Address - Phone:615-942-0240
Mailing Address - Fax:
Practice Address - Street 1:4355 SOUTH LEE STREET
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518
Practice Address - Country:US
Practice Address - Phone:770-271-0277
Practice Address - Fax:770-221-2809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility