Provider Demographics
NPI:1427017920
Name:THE PLACE AT POOLER LLC
Entity Type:Organization
Organization Name:THE PLACE AT POOLER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSING HOME ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMNIE
Authorized Official - Middle Name:CHAN
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:912-748-6840
Mailing Address - Street 1:508 S ROGERS STREET
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322
Mailing Address - Country:US
Mailing Address - Phone:912-748-6840
Mailing Address - Fax:912-748-5418
Practice Address - Street 1:508 S ROGERS STREET
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322
Practice Address - Country:US
Practice Address - Phone:912-748-6840
Practice Address - Fax:912-748-5418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2022-07-21
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
GA002387418Medicaid
115293Medicare ID - Type Unspecified