Basic Information
| Provider Information | |||||||||
| NPI: | 1619516093 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WICKSHIRE CANTON OPCO LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 750 OLD HICKORY BLVD | ||||||||
| Address2: | BUILDING ONE SUITE 125 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159420240 | ||||||||
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| Practice Location | |||||||||
| Address1: | 125 RIVERSTONE TERRACE | ||||||||
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| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707209669 | ||||||||
| FaxNumber: | 6788803689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2020 | ||||||||
| LastUpdateDate: | 01/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | OKEEFE | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6159420240 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | JD | ||||||||
| NPICertificationDate: | 01/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.