Provider Demographics
NPI:1710989462
Name:EAGLES NEST TRUCK STATION INC
Entity Type:Organization
Organization Name:EAGLES NEST TRUCK STATION INC
Other - Org Name:MOSS OAKS HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:PENLEY
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:706-855-1773
Mailing Address - Street 1:PO BOX 929
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-0929
Mailing Address - Country:US
Mailing Address - Phone:912-748-6842
Mailing Address - Fax:912-748-5214
Practice Address - Street 1:508 S ROGERS ST
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-3116
Practice Address - Country:US
Practice Address - Phone:912-748-6842
Practice Address - Fax:912-748-5214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00238741AMedicaid
1041060001OtherDME
GA00238741AMedicaid