Provider Demographics
NPI:1770573412
Name:PRESBYTERIAN VILLAGE, AUSTELL, INC.
Entity type:Organization
Organization Name:PRESBYTERIAN VILLAGE, AUSTELL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ARRENDALE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:229-263-6193
Mailing Address - Street 1:PO BOX 926
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31643-0926
Mailing Address - Country:US
Mailing Address - Phone:229-263-6191
Mailing Address - Fax:229-263-6195
Practice Address - Street 1:2000 E WEST CONNECTOR
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1194
Practice Address - Country:US
Practice Address - Phone:770-819-7000
Practice Address - Fax:770-819-7497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00362832AMedicaid
GA1002490001Medicare ID - Type UnspecifiedDMRC PROVIDER #
GA115490Medicare Oscar/Certification