Provider Demographics
NPI:1720239619
Name:GLENWOOD HEALTHCARE, LLC
Entity Type:Organization
Organization Name:GLENWOOD HEALTHCARE, LLC
Other - Org Name:GLENWOOD HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-644-0471
Mailing Address - Street 1:PO BOX 612
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31598-0612
Mailing Address - Country:US
Mailing Address - Phone:912-523-5102
Mailing Address - Fax:912-523-5704
Practice Address - Street 1:41 N FIFTH ST
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30428-0869
Practice Address - Country:US
Practice Address - Phone:912-523-5102
Practice Address - Fax:912-523-5704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-09
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA701562744AMedicaid
115703Medicare Oscar/Certification