Provider Demographics
NPI:1548701006
Name:SKYLARK ADH-JOHNS CREEK, LLC
Entity type:Organization
Organization Name:SKYLARK ADH-JOHNS CREEK, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:MORGENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-476-8400
Mailing Address - Street 1:4265 JOHNS CREEK PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6038
Mailing Address - Country:US
Mailing Address - Phone:770-476-8400
Mailing Address - Fax:678-646-0602
Practice Address - Street 1:4265 JOHNS CREEK PKWY STE B
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6038
Practice Address - Country:US
Practice Address - Phone:770-476-8400
Practice Address - Fax:678-646-0602
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SKYLARK SENIOR CARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAADC000089261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA383600128AMedicaid
GA718343569AMedicaid
GA383600128BMedicaid