Provider Demographics
NPI:1700079829
Name:WILKINSON GEORGIA IDAHO SENIOR HOUSING LLC
Entity Type:Organization
Organization Name:WILKINSON GEORGIA IDAHO SENIOR HOUSING LLC
Other - Org Name:WATERFORD GARDENS
Other - Org Type:Other Name
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-747-3373
Mailing Address - Street 1:78 CENTENNIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-7900
Mailing Address - Country:US
Mailing Address - Phone:541-747-3373
Mailing Address - Fax:541-747-0673
Practice Address - Street 1:4484 N SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-6402
Practice Address - Country:US
Practice Address - Phone:770-350-2393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility