Provider Demographics
NPI:1629411277
Name:MAJESTIC SUNZ LIFE CENTER
Entity Type:Organization
Organization Name:MAJESTIC SUNZ LIFE CENTER
Other - Org Name:BOLTON LIVING AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ZEPHANIAH
Authorized Official - Middle Name:DWAYNE
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-587-3906
Mailing Address - Street 1:1091 BOLTON CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-2616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 LANTANA WAY
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-4171
Practice Address - Country:US
Practice Address - Phone:706-569-1133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-14
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038-R-1778251E00000X, 314000000X
CLA001048320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251E00000XAgenciesHome Health
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility