Basic Information
| Provider Information | |||||||||
| NPI: | 1215112255 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAUREL BAYE HEALTHCARE OF LAKE LANIER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2451 PEACHTREE INDUSTRIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | BUFORD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305182418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706142800 | ||||||||
| FaxNumber: | 7709325754 | ||||||||
| Practice Location | |||||||||
| Address1: | 2451 PEACHTREE INDUSTRIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | BUFORD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305182418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706142800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2008 | ||||||||
| LastUpdateDate: | 07/21/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 08/18/2008 | ||||||||
| NPIReactivationDate: | 09/24/2008 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRIECO | ||||||||
| AuthorizedOfficialFirstName: | KYLIE | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 8432166800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 10671659 | GA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 000140456A | 05 | GA | MEDICAID |