Provider Demographics
NPI:1326119710
Name:PEACH STATE NURSING AGENCY
Entity Type:Organization
Organization Name:PEACH STATE NURSING AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-453-3369
Mailing Address - Street 1:PO BOX 326
Mailing Address - Street 2:140 WEST WASHINGTON ST.
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31059-0326
Mailing Address - Country:US
Mailing Address - Phone:478-453-3369
Mailing Address - Fax:478-453-1131
Practice Address - Street 1:140 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-3434
Practice Address - Country:US
Practice Address - Phone:478-453-3369
Practice Address - Fax:478-453-1131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005-R-0003251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health