Provider Demographics
NPI:1710965033
Name:DOUGLASVILLE NURSING AND REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:DOUGLASVILLE NURSING AND REHABILITATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:NORBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-662-4955
Mailing Address - Street 1:P O BOX 0428
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127
Mailing Address - Country:US
Mailing Address - Phone:716-662-4955
Mailing Address - Fax:716-667-9230
Practice Address - Street 1:4028 HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-3530
Practice Address - Country:US
Practice Address - Phone:770-942-7111
Practice Address - Fax:770-489-1268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-048-1741314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00141083AMedicaid
GA00141083AMedicaid