Provider Demographics
NPI:1376854372
Name:SOUTHEAST SENIOR CARE MANGMENT GROUP
Entity Type:Organization
Organization Name:SOUTHEAST SENIOR CARE MANGMENT GROUP
Other - Org Name:MEMORY LANE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHENEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-258-8600
Mailing Address - Street 1:501 MITCHELL AVE
Mailing Address - Street 2:
Mailing Address - City:BOWDON
Mailing Address - State:GA
Mailing Address - Zip Code:30108-1407
Mailing Address - Country:US
Mailing Address - Phone:770-258-8600
Mailing Address - Fax:
Practice Address - Street 1:501 MITCHELL AVE
Practice Address - Street 2:
Practice Address - City:BOWDON
Practice Address - State:GA
Practice Address - Zip Code:30108-1407
Practice Address - Country:US
Practice Address - Phone:770-258-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022-03-010-9310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility