Provider Demographics
NPI:1659307957
Name:FAYETTE COUNTY NURSING HOME LLC
Entity Type:Organization
Organization Name:FAYETTE COUNTY NURSING HOME LLC
Other - Org Name:SOUTHLAND HEALTH AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-631-9000
Mailing Address - Street 1:PO BOX 2747
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-0747
Mailing Address - Country:US
Mailing Address - Phone:770-631-9000
Mailing Address - Fax:770-487-2788
Practice Address - Street 1:151 WISDOM RD
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3937
Practice Address - Country:US
Practice Address - Phone:770-631-9000
Practice Address - Fax:770-487-2788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-056-1784314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000409054AMedicaid
51043457 002OtherBCBS
115460Medicare Oscar/Certification