Provider Demographics
NPI:1932148392
Name:HERITAGE INN OF BARNESVILLE LLC
Entity Type:Organization
Organization Name:HERITAGE INN OF BARNESVILLE LLC
Other - Org Name:HERITAGE INN OF BARNESVILLE HEALTH AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LESLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GERVIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-358-2485
Mailing Address - Street 1:946 VETERANS PARKWAY
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30204-3771
Mailing Address - Country:US
Mailing Address - Phone:770-358-2485
Mailing Address - Fax:770-358-3917
Practice Address - Street 1:946 VETERANS PARKWAY
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30204-3771
Practice Address - Country:US
Practice Address - Phone:770-358-2485
Practice Address - Fax:770-358-3917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-085-1700314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00143613AMedicaid
51000723 001OtherBCBS
115447Medicare Oscar/Certification