Provider Demographics
NPI:1619403805
Name:QUENCIE'S MANOR LLC
Entity Type:Organization
Organization Name:QUENCIE'S MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-832-5479
Mailing Address - Street 1:2104 JEFFERSONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-4517
Mailing Address - Country:US
Mailing Address - Phone:478-832-5479
Mailing Address - Fax:478-239-5148
Practice Address - Street 1:2104 JEFFERSONVILLE RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-4517
Practice Address - Country:US
Practice Address - Phone:478-832-5479
Practice Address - Fax:478-239-5148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-07
Last Update Date:2017-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCH009157320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities