Provider Demographics
NPI:1982628491
Name:MONTEZUMA HEALTH CARE CENTER LLC
Entity Type:Organization
Organization Name:MONTEZUMA HEALTH CARE CENTER LLC
Other - Org Name:MONTEZUMA HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRISP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-472-8168
Mailing Address - Street 1:PO BOX 639
Mailing Address - Street 2:
Mailing Address - City:MONTEZUMA
Mailing Address - State:GA
Mailing Address - Zip Code:31063-0639
Mailing Address - Country:US
Mailing Address - Phone:478-472-8168
Mailing Address - Fax:478-472-2373
Practice Address - Street 1:506 SUMTER ST
Practice Address - Street 2:
Practice Address - City:MONTEZUMA
Practice Address - State:GA
Practice Address - Zip Code:31063-1734
Practice Address - Country:US
Practice Address - Phone:478-472-8168
Practice Address - Fax:478-472-2373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-094-1731261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA287282627CMedicaid