Provider Demographics
NPI:1508948134
Name:FORUM GROUP @ MT. BERRY NURSING & REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:FORUM GROUP @ MT. BERRY NURSING & REHABILITATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:DALYN
Authorized Official - Last Name:HOUSER
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:706-291-8600
Mailing Address - Street 1:1700 WATER PL SE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-2006
Mailing Address - Country:US
Mailing Address - Phone:678-213-2700
Mailing Address - Fax:678-213-2705
Practice Address - Street 1:2 THREE MILE RD NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-9764
Practice Address - Country:US
Practice Address - Phone:706-291-4606
Practice Address - Fax:706-235-8145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10571818314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
115311Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER