Provider Demographics
NPI:1750442471
Name:CHAMBER HEALTH CARE SOCIETY LLC
Entity Type:Organization
Organization Name:CHAMBER HEALTH CARE SOCIETY LLC
Other - Org Name:LIFE CARE CENTER
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 1:176 LINCOLN AVE
Mailing Address - Street 2:P.O. BOX 1289
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750-8447
Mailing Address - Country:US
Mailing Address - Phone:229-423-5621
Mailing Address - Fax:229-423-8723
Practice Address - Street 1:176 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-8447
Practice Address - Country:US
Practice Address - Phone:229-423-5621
Practice Address - Fax:229-423-8723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-009-1596314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00140665AMedicaid
GA11-5654Medicare ID - Type UnspecifiedMEDICARE NUMBER