Provider Demographics
NPI:1811032030
Name:LEISURE LIFE CARE HOME INC
Entity type:Organization
Organization Name:LEISURE LIFE CARE HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:DORA
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-892-2058
Mailing Address - Street 1:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036
Mailing Address - Country:US
Mailing Address - Phone:478-892-2058
Mailing Address - Fax:478-892-2058
Practice Address - Street 1:301 BEACHAM STREET
Practice Address - Street 2:
Practice Address - City:UNADILLA
Practice Address - State:GA
Practice Address - Zip Code:31091
Practice Address - Country:US
Practice Address - Phone:478-892-2058
Practice Address - Fax:478-892-2058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00535477AMedicaid