Provider Demographics
NPI:1790252427
Name:COLISEUM DRIVE ASSOCIATES LLC
Entity Type:Organization
Organization Name:COLISEUM DRIVE ASSOCIATES LLC
Other - Org Name:MACON REHABILITATION AND HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-282-4755
Mailing Address - Street 1:3000 OLD ALABAMA RD STE 119-403
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-5860
Mailing Address - Country:US
Mailing Address - Phone:404-282-4755
Mailing Address - Fax:
Practice Address - Street 1:505 COLISEUM DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3840
Practice Address - Country:US
Practice Address - Phone:678-987-3819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-31
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility