Provider Demographics
NPI:1689614935
Name:CLINCH HEALTHCARE LLC
Entity Type:Organization
Organization Name:CLINCH HEALTHCARE LLC
Other - Org Name:CLINCH HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TYGH
Authorized Official - Middle Name:
Authorized Official - Last Name:BROGDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-650-8773
Mailing Address - Street 1:390 SWEAT ST
Mailing Address - Street 2:
Mailing Address - City:HOMERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31634-2302
Mailing Address - Country:US
Mailing Address - Phone:912-487-5328
Mailing Address - Fax:912-487-2460
Practice Address - Street 1:390 SWEAT ST
Practice Address - Street 2:
Practice Address - City:HOMERVILLE
Practice Address - State:GA
Practice Address - Zip Code:31634-2302
Practice Address - Country:US
Practice Address - Phone:912-487-5328
Practice Address - Fax:912-487-2460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-032-1862314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000142106AMedicaid
11-5635Medicare ID - Type UnspecifiedMUTUAL OF OMAHA