Provider Demographics
NPI:1922164722
Name:LAKEVIEW MANOR, LLC
Entity Type:Organization
Organization Name:LAKEVIEW MANOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-267-5511
Mailing Address - Street 1:1321 PRICE MILL RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:GA
Mailing Address - Zip Code:30650-2867
Mailing Address - Country:US
Mailing Address - Phone:706-342-7159
Mailing Address - Fax:
Practice Address - Street 1:1321 PRICE MILL RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:GA
Practice Address - Zip Code:30650-2867
Practice Address - Country:US
Practice Address - Phone:706-342-7159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility