Provider Demographics
NPI:1245278290
Name:MCDUFFIE COUNTY NURSING HOME LLC
Entity type:Organization
Organization Name:MCDUFFIE COUNTY NURSING HOME LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:PITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-595-5574
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-1080
Mailing Address - Country:US
Mailing Address - Phone:706-595-5574
Mailing Address - Fax:706-595-6342
Practice Address - Street 1:511 MOUNT PLEASANT RD
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-8140
Practice Address - Country:US
Practice Address - Phone:706-595-5574
Practice Address - Fax:706-595-6342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-138-1715314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
51001187 001OtherBCBS
GA00143261AMedicaid
115365Medicare Oscar/Certification