Provider Demographics
NPI:1740341312
Name:PORTER FIELD HEALTH & REHAB CENTER LLC
Entity type:Organization
Organization Name:PORTER FIELD HEALTH & REHAB CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TYGH
Authorized Official - Middle Name:
Authorized Official - Last Name:BROGDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-650-8773
Mailing Address - Street 1:3051 WHITESIDE RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31216-6209
Mailing Address - Country:US
Mailing Address - Phone:478-788-1421
Mailing Address - Fax:478-781-0987
Practice Address - Street 1:3051 WHITESIDE RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31216-6209
Practice Address - Country:US
Practice Address - Phone:478-788-1421
Practice Address - Fax:478-781-0987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10111615314000000X
GA10111916314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00222582AMedicaid
GA115636Medicare Oscar/Certification