Provider Demographics
NPI:1457630311
Name:DOGWOOD BLUFF PERSONAL CARE HOME
Entity Type:Organization
Organization Name:DOGWOOD BLUFF PERSONAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-974-7704
Mailing Address - Street 1:266 PONY LAKE LN
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-6309
Mailing Address - Country:US
Mailing Address - Phone:706-974-7704
Mailing Address - Fax:770-536-0776
Practice Address - Street 1:266 PONY LAKE LN
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-6309
Practice Address - Country:US
Practice Address - Phone:706-974-7704
Practice Address - Fax:770-536-0776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-10
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000604546AMedicaid