Provider Demographics
NPI:1639103690
Name:PLACE AT AUGUSTA, LLC
Entity Type:Organization
Organization Name:PLACE AT AUGUSTA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:W
Authorized Official - Middle Name:MELISSA
Authorized Official - Last Name:ODEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-585-4444
Mailing Address - Street 1:820 STEVENS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9251
Mailing Address - Country:US
Mailing Address - Phone:706-860-6622
Mailing Address - Fax:706-860-6532
Practice Address - Street 1:820 STEVENS CREEK RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-9251
Practice Address - Country:US
Practice Address - Phone:615-706-8606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000213463AMedicaid
GA11-5278Medicare ID - Type Unspecified