Provider Demographics
NPI:1639441421
Name:SMITH PERSONAL CARE HOME 1AND 2 INC
Entity Type:Organization
Organization Name:SMITH PERSONAL CARE HOME 1AND 2 INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAURITA
Authorized Official - Middle Name:H
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-237-2123
Mailing Address - Street 1:309 ADVANCE ST
Mailing Address - Street 2:
Mailing Address - City:SWAINSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30401-3675
Mailing Address - Country:US
Mailing Address - Phone:478-237-2123
Mailing Address - Fax:478-237-2129
Practice Address - Street 1:309 ADVANCE ST
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401-3675
Practice Address - Country:US
Practice Address - Phone:478-237-2123
Practice Address - Fax:478-237-2129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053010771315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA467317926AMedicaid