Basic Information
| Provider Information | |||||||||
| NPI: | 1114118288 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LP MARIETTA LLC | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SIGNATURE HEALTHCARE OF MARIETTA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 811 KENNESAW AVE NW | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704222451 | ||||||||
| FaxNumber: | 7704992235 | ||||||||
| Practice Location | |||||||||
| Address1: | 811 KENNESAW AVE NW | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704222451 | ||||||||
| FaxNumber: | 7704992235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2007 | ||||||||
| LastUpdateDate: | 03/19/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRISON | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5025687800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.