Provider Demographics
NPI:1497195051
Name:GREEN STREET NH LLC
Entity Type:Organization
Organization Name:GREEN STREET NH LLC
Other - Org Name:PROVIDENCE HEALTHCARE OF THOMASTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHMAYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-650-7086
Mailing Address - Street 1:1011 S GREEN ST
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-4643
Mailing Address - Country:US
Mailing Address - Phone:706-647-6693
Mailing Address - Fax:706-648-9255
Practice Address - Street 1:1011 S GREEN ST
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-4643
Practice Address - Country:US
Practice Address - Phone:706-647-6693
Practice Address - Fax:706-648-9255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
115484Medicare Oscar/Certification