Provider Demographics
NPI:1578969051
Name:OCONEE HOUSE SENIOR LIVING
Entity Type:Organization
Organization Name:OCONEE HOUSE SENIOR LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADYS
Authorized Official - Middle Name:
Authorized Official - Last Name:PERERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-474-3722
Mailing Address - Street 1:134 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUTLEDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30663-2370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:126 PARKS MILL RD
Practice Address - Street 2:
Practice Address - City:BUCKHEAD
Practice Address - State:GA
Practice Address - Zip Code:30625-3200
Practice Address - Country:US
Practice Address - Phone:706-485-1179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA117030011310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA908375602Medicaid