Provider Demographics
NPI:1255337341
Name:CHC-PINE KNOLL NURSING & REHAB CTR, LLC
Entity type:Organization
Organization Name:CHC-PINE KNOLL NURSING & REHAB CTR, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:PALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-390-4363
Mailing Address - Street 1:156 PINE KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-2451
Mailing Address - Country:US
Mailing Address - Phone:770-832-8243
Mailing Address - Fax:770-832-8221
Practice Address - Street 1:156 PINE KNOLL DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-2451
Practice Address - Country:US
Practice Address - Phone:770-832-8243
Practice Address - Fax:770-832-8221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10221757314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00142458AMedicaid
GA115443Medicare Oscar/Certification