Provider Demographics
NPI:1265479133
Name:HERITAGE INN OF SANDERSVILLE LLC
Entity type:Organization
Organization Name:HERITAGE INN OF SANDERSVILLE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-552-3015
Mailing Address - Street 1:PO BOX 388
Mailing Address - Street 2:
Mailing Address - City:SANDERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31082-0388
Mailing Address - Country:US
Mailing Address - Phone:478-552-3015
Mailing Address - Fax:478-552-1767
Practice Address - Street 1:652 FERNCREST DR
Practice Address - Street 2:
Practice Address - City:SANDERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31082-1863
Practice Address - Country:US
Practice Address - Phone:478-552-3015
Practice Address - Fax:478-552-1767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-150-1704314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00412678AMedicaid
51001283 001OtherBCBS
GA00412678AMedicaid