Provider Demographics
NPI:1255584108
Name:PIKE MANOR INC.
Entity type:Organization
Organization Name:PIKE MANOR INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:CEO/CFO; PT
Authorized Official - Phone:770-567-0020
Mailing Address - Street 1:10642 HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:GA
Mailing Address - Zip Code:30295-3192
Mailing Address - Country:US
Mailing Address - Phone:770-567-0200
Mailing Address - Fax:770-567-0010
Practice Address - Street 1:10642 HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:GA
Practice Address - Zip Code:30295-3192
Practice Address - Country:US
Practice Address - Phone:770-567-0200
Practice Address - Fax:770-567-0010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-23
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA114030011310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000946789AMedicaid