Provider Demographics
NPI:1568748317
Name:FRIENDSHIP-LTC, LLC
Entity Type:Organization
Organization Name:FRIENDSHIP-LTC, LLC
Other - Org Name:FRIENDSHIP HOUSE OF CENTRALIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAREN
Authorized Official - Middle Name:G
Authorized Official - Last Name:DOUSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-522-2436
Mailing Address - Street 1:10945 STATE BRIDGE RD
Mailing Address - Street 2:SUITE 401-470
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-8164
Mailing Address - Country:US
Mailing Address - Phone:678-522-2436
Mailing Address - Fax:770-663-4539
Practice Address - Street 1:1000 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3002
Practice Address - Country:US
Practice Address - Phone:678-522-2436
Practice Address - Fax:770-663-4539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility