Provider Demographics
NPI:1679514434
Name:JESUP HEALTHCARE LLC
Entity Type:Organization
Organization Name:JESUP HEALTHCARE LLC
Other - Org Name:JESUP HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TYGH
Authorized Official - Middle Name:ANGWIN
Authorized Official - Last Name:BROGDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-650-8773
Mailing Address - Street 1:3100 SAVANNAH HWY
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-5514
Mailing Address - Country:US
Mailing Address - Phone:912-427-6873
Mailing Address - Fax:912-530-6713
Practice Address - Street 1:3100 SAVANNAH HWY
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-5514
Practice Address - Country:US
Practice Address - Phone:912-427-6873
Practice Address - Fax:912-530-6713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-151-1864314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000142689AMedicaid
11-5503Medicare ID - Type UnspecifiedMUTUAL OF OMAHA