Provider Demographics
NPI:1487648010
Name:GLASCOCK COUNTY HEALTH CARE LLC
Entity Type:Organization
Organization Name:GLASCOCK COUNTY HEALTH CARE LLC
Other - Org Name:THE SOUTHERN LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JIMMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-598-2167
Mailing Address - Street 1:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:GIBSON
Mailing Address - State:GA
Mailing Address - Zip Code:30810-0248
Mailing Address - Country:US
Mailing Address - Phone:706-598-2167
Mailing Address - Fax:706-598-3802
Practice Address - Street 1:434 BEALL SPRINGS RD
Practice Address - Street 2:
Practice Address - City:GIBSON
Practice Address - State:GA
Practice Address - Zip Code:30810-4224
Practice Address - Country:US
Practice Address - Phone:706-598-2167
Practice Address - Fax:706-598-3802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-09
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062-02-001-1310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000258706AMedicaid