Provider Demographics
NPI:1568860393
Name:SOUTHERN MANOR SENIOR LIVING, LLC
Entity Type:Organization
Organization Name:SOUTHERN MANOR SENIOR LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHERRER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-678-3330
Mailing Address - Street 1:184 PINE LN
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30673-4035
Mailing Address - Country:US
Mailing Address - Phone:706-678-3330
Mailing Address - Fax:706-678-4440
Practice Address - Street 1:184 PINE LN
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:GA
Practice Address - Zip Code:30673-4035
Practice Address - Country:US
Practice Address - Phone:706-678-3330
Practice Address - Fax:706-678-4440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-10
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCH008530310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003156697AMedicaid
GA003158657AMedicaid