Provider Demographics
NPI:1841235454
Name:EVANS COUNTY LTC LLC
Entity Type:Organization
Organization Name:EVANS COUNTY LTC LLC
Other - Org Name:CAMELLIA HEALTH AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTTOMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-739-2245
Mailing Address - Street 1:PO BOX 712
Mailing Address - Street 2:
Mailing Address - City:CLAXTON
Mailing Address - State:GA
Mailing Address - Zip Code:30417-0712
Mailing Address - Country:US
Mailing Address - Phone:912-739-2245
Mailing Address - Fax:912-739-3762
Practice Address - Street 1:700 E LONG ST
Practice Address - Street 2:
Practice Address - City:CLAXTON
Practice Address - State:GA
Practice Address - Zip Code:30417-5916
Practice Address - Country:US
Practice Address - Phone:912-739-2245
Practice Address - Fax:912-739-3762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-054-1901314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000140588AMedicaid
GA000140588AMedicaid