Provider Demographics
NPI:1427369966
Name:TENNILLE RETIREMENT HOME, LLC
Entity Type:Organization
Organization Name:TENNILLE RETIREMENT HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-862-9051
Mailing Address - Street 1:PO BOX 2028
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:GA
Mailing Address - Zip Code:31006-2028
Mailing Address - Country:US
Mailing Address - Phone:478-862-9051
Mailing Address - Fax:
Practice Address - Street 1:525 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TENNILLE
Practice Address - State:GA
Practice Address - Zip Code:31089-1128
Practice Address - Country:US
Practice Address - Phone:478-862-9051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA150-03-001-1310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA115769937AMedicaid