Provider Demographics
NPI:1700888740
Name:LTC HEALTHCARE OF STATESBORO INC
Entity Type:Organization
Organization Name:LTC HEALTHCARE OF STATESBORO INC
Other - Org Name:WESTWOOD NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-993-4000
Mailing Address - Street 1:995 CANTON ST STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-4240
Mailing Address - Country:US
Mailing Address - Phone:770-993-4000
Mailing Address - Fax:
Practice Address - Street 1:101 STOCKYARD RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1343
Practice Address - Country:US
Practice Address - Phone:912-764-6005
Practice Address - Fax:912-764-4099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000370F62AMedicaid
GA115601Medicare Oscar/Certification