Provider Demographics
NPI:1821580440
Name:LCS BRANDON WILDE LLC
Entity Type:Organization
Organization Name:LCS BRANDON WILDE LLC
Other - Org Name:THE PAVILION AT BRANDON WILDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER OF MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRIDGEWATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-875-4500
Mailing Address - Street 1:4275 OWENS RD
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3066
Mailing Address - Country:US
Mailing Address - Phone:706-868-9800
Mailing Address - Fax:
Practice Address - Street 1:4275 OWENS RD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809
Practice Address - Country:US
Practice Address - Phone:706-868-9800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-30
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
GA1-036-2130314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility