Provider Demographics
NPI:1770769119
Name:KNOLLWOOD HEALTHCARE LLC
Entity type:Organization
Organization Name:KNOLLWOOD HEALTHCARE 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 1:3151 KNOLLWOOD DR # A
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36693-2753
Mailing Address - Country:US
Mailing Address - Phone:251-661-7608
Mailing Address - Fax:
Practice Address - Street 1:3151 KNOLLWOOD DR # A
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36693-2753
Practice Address - Country:US
Practice Address - Phone:251-661-7608
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRENTWOOD HEALTHCARE HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-16
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALN4926314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL47579902Medicaid
AL47579902Medicaid