Provider Demographics
NPI:1821260217
Name:EMERALD ISLES PCH, INC
Entity Type:Organization
Organization Name:EMERALD ISLES PCH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILITY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-509-0533
Mailing Address - Street 1:1402 SHADOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-4032
Mailing Address - Country:US
Mailing Address - Phone:770-509-0533
Mailing Address - Fax:
Practice Address - Street 1:1402 SHADOWBROOK DR
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-4032
Practice Address - Country:US
Practice Address - Phone:770-509-0533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA088Medicaid
GA244Medicaid
GA244Medicaid
GA380Medicare UPIN