Basic Information
| Provider Information | |||||||||
| NPI: | 1891095162 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE OAKS - BETHANY SKILLED NURSING, LLC | ||||||||
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| OtherOrganizationName: | THE OAKS - BETHANY SKILLED NURSING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1626 JEURGENS COURT | ||||||||
| Address2: | |||||||||
| City: | NORCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703796200 | ||||||||
| FaxNumber: | 7709315278 | ||||||||
| Practice Location | |||||||||
| Address1: | 1305 EAST NORTH STREET | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304748624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125377922 | ||||||||
| FaxNumber: | 9125370216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2010 | ||||||||
| LastUpdateDate: | 06/27/2014 | ||||||||
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| AuthorizedOfficialLastName: | PRUITT | ||||||||
| AuthorizedOfficialFirstName: | NEIL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 7702796200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | GA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00140258A | 05 | GA | MEDICAID |