Provider Demographics
NPI:1801134739
Name:MACKLANDER, LLC
Entity type:Organization
Organization Name:MACKLANDER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-854-0555
Mailing Address - Street 1:1514 BALDWIN LAKES DR
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-5887
Mailing Address - Country:US
Mailing Address - Phone:706-854-0555
Mailing Address - Fax:706-651-9677
Practice Address - Street 1:1514 BALDWIN LAKES DR
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-5887
Practice Address - Country:US
Practice Address - Phone:706-854-0555
Practice Address - Fax:706-651-9677
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MACKLANDER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036-R-0525251J00000X, 261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA366878280BMedicaid
GA366878280AMedicaid