Provider Demographics
NPI:1922003177
Name:CARROLLTON MANOR INC
Entity Type:Organization
Organization Name:CARROLLTON MANOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-834-1737
Mailing Address - Street 1:PO BOX 2398
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30112-0044
Mailing Address - Country:US
Mailing Address - Phone:770-834-1737
Mailing Address - Fax:770-836-1223
Practice Address - Street 1:2455 OAK GROVE CHURCH RD
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-9513
Practice Address - Country:US
Practice Address - Phone:770-834-1737
Practice Address - Fax:770-836-1223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-022-1170314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00140852AMedicaid
GA00140852AMedicaid