Provider Demographics
NPI:1477595403
Name:BRENTWOOD TERRACE HEALTH CENTER, LLC
Entity type:Organization
Organization Name:BRENTWOOD TERRACE HEALTH CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-554-4425
Mailing Address - Street 1:PO BOX 907
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30830-0907
Mailing Address - Country:US
Mailing Address - Phone:706-554-4425
Mailing Address - Fax:706-554-6163
Practice Address - Street 1:115 BRENTWOOD DR
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:GA
Practice Address - Zip Code:30830-4519
Practice Address - Country:US
Practice Address - Phone:706-554-4425
Practice Address - Fax:706-554-6163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-017-1711314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00140071AMedicaid
51001331 001OtherBCBS
GA115361Medicare Oscar/Certification