Provider Demographics
NPI:1598945065
Name:SAS - MORAN LAKE, INC.
Entity Type:Organization
Organization Name:SAS - MORAN LAKE, INC.
Other - Org Name:EVERGREEN HEALTH & REHABLITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VC/COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:D
Authorized Official - Last Name:FORRISTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-736-3028
Mailing Address - Street 1:3100 FIVE FORKS TRICKUM RD SW
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-1890
Mailing Address - Country:US
Mailing Address - Phone:770-736-3028
Mailing Address - Fax:770-736-3345
Practice Address - Street 1:139 MORAN LAKE RD NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-7767
Practice Address - Country:US
Practice Address - Phone:770-736-3028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility