Provider Demographics
NPI:1760688550
Name:COVINGTON MANOR NURSING HOME LLC
Entity Type:Organization
Organization Name:COVINGTON MANOR NURSING HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-783-1623
Mailing Address - Street 1:PO BOX 1038
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036-7038
Mailing Address - Country:US
Mailing Address - Phone:478-783-4988
Mailing Address - Fax:
Practice Address - Street 1:440 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:HAWKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31036
Practice Address - Country:US
Practice Address - Phone:478-783-4988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COVINGTON MANOR NURSING HOME LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-27
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BN1400X
GA106867332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000515534AMedicaid
GA4847290001Medicare NSC