Provider Demographics
NPI:1700167574
Name:MOLENA EXTENDED CARE, LLC
Entity Type:Organization
Organization Name:MOLENA EXTENDED CARE, LLC
Other - Org Name:MOLENA HEALTH & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LOUISA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WINGET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-974-0006
Mailing Address - Street 1:185 HILL ST
Mailing Address - Street 2:
Mailing Address - City:MOLENA
Mailing Address - State:GA
Mailing Address - Zip Code:30258-3115
Mailing Address - Country:US
Mailing Address - Phone:770-884-5138
Mailing Address - Fax:770-884-5484
Practice Address - Street 1:185 HILL ST
Practice Address - Street 2:
Practice Address - City:MOLENA
Practice Address - State:GA
Practice Address - Zip Code:30258-3115
Practice Address - Country:US
Practice Address - Phone:770-884-5138
Practice Address - Fax:770-884-5484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-07
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000142029AMedicaid
115693Medicare Oscar/Certification