Provider Demographics
NPI:1780122010
Name:PUGH'S PERSONAL CARE HOME
Entity type:Organization
Organization Name:PUGH'S PERSONAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:F
Authorized Official - Last Name:PUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-254-0546
Mailing Address - Street 1:5834 ST MATTHEW ST JOHN CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:DONALSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:39845
Mailing Address - Country:US
Mailing Address - Phone:229-524-1015
Mailing Address - Fax:229-524-1120
Practice Address - Street 1:5834 ST MATTHEWS ST JOHN CHURCH RD
Practice Address - Street 2:
Practice Address - City:DONALSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:39845-3550
Practice Address - Country:US
Practice Address - Phone:229-524-1015
Practice Address - Fax:229-524-1120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCH008762320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities