Provider Demographics
NPI:1598766040
Name:FORREST LAKE HEALTH CARE INC
Entity Type:Organization
Organization Name:FORREST LAKE HEALTH CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:PENLEY
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:706-855-1773
Mailing Address - Street 1:PO BOX 211529
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30917-1529
Mailing Address - Country:US
Mailing Address - Phone:706-863-6033
Mailing Address - Fax:706-863-2661
Practice Address - Street 1:409 PLEASANT HOME RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-3523
Practice Address - Country:US
Practice Address - Phone:706-863-6033
Practice Address - Fax:706-863-2661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00142535AMedicaid
1040940001OtherDME
115308Medicare ID - Type Unspecified