Provider Demographics
NPI:1891095162
Name:THE OAKS - BETHANY SKILLED NURSING, LLC
Entity Type:Organization
Organization Name:THE OAKS - BETHANY SKILLED NURSING, LLC
Other - Org Name:THE OAKS - BETHANY SKILLED NURSING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:L
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:770-279-6200
Mailing Address - Street 1:1626 JEURGENS COURT
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093
Mailing Address - Country:US
Mailing Address - Phone:770-379-6200
Mailing Address - Fax:770-931-5278
Practice Address - Street 1:1305 EAST NORTH STREET
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8624
Practice Address - Country:US
Practice Address - Phone:912-537-7922
Practice Address - Fax:912-537-0216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-02
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00140258AMedicaid
GA115705Medicare Oscar/Certification