Provider Demographics
NPI:1750553996
Name:FORT GAINES OPERATOR LLC
Entity type:Organization
Organization Name:FORT GAINES OPERATOR LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WALDEMAR
Authorized Official - Middle Name:W
Authorized Official - Last Name:SELTZER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:229-768-2521
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:FORT GAINES
Mailing Address - State:GA
Mailing Address - Zip Code:39851-0160
Mailing Address - Country:US
Mailing Address - Phone:229-768-2521
Mailing Address - Fax:229-768-2466
Practice Address - Street 1:101 HARTFORD RD W
Practice Address - Street 2:
Practice Address - City:FORT GAINES
Practice Address - State:GA
Practice Address - Zip Code:39851-4331
Practice Address - Country:US
Practice Address - Phone:229-768-2521
Practice Address - Fax:229-768-2466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-030-1168314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000140599AMedicaid
GA000140599AMedicaid