Provider Demographics
NPI:1770755951
Name:ROBERTA OPERATOR LLC
Entity type:Organization
Organization Name:ROBERTA OPERATOR LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-836-3101
Mailing Address - Street 1:420 MYRTLE DR
Mailing Address - Street 2:
Mailing Address - City:ROBERTA
Mailing Address - State:GA
Mailing Address - Zip Code:31078-9752
Mailing Address - Country:US
Mailing Address - Phone:478-836-3101
Mailing Address - Fax:478-836-2700
Practice Address - Street 1:420 MYRTLE DR
Practice Address - Street 2:
Practice Address - City:ROBERTA
Practice Address - State:GA
Practice Address - Zip Code:31078-9752
Practice Address - Country:US
Practice Address - Phone:478-836-3101
Practice Address - Fax:478-836-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-039-1080314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000142777AMedicaid
115523Medicare Oscar/Certification