Provider Demographics
NPI:1881680601
Name:CORDELE HEALTH AND REHABILITATION CENTER, INC.
Entity Type:Organization
Organization Name:CORDELE HEALTH AND REHABILITATION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:FALLAW
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:229-268-7510
Mailing Address - Street 1:1106 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-3679
Mailing Address - Country:US
Mailing Address - Phone:229-273-1227
Mailing Address - Fax:229-273-0930
Practice Address - Street 1:1106 N 4TH ST
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3679
Practice Address - Country:US
Practice Address - Phone:229-273-1227
Practice Address - Fax:229-273-0930
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROHEALTH RESOURCE GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-27
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-040-1794314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00059892AMedicaid
GA115429Medicare Oscar/Certification