Provider Demographics
NPI:1639652944
Name:LYNCHBURG HEALTHCARE, LLC
Entity type:Organization
Organization Name:LYNCHBURG HEALTHCARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:MITTLEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-282-3271
Mailing Address - Street 1:3050 ROYAL BLVD S STE 190
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-1417
Mailing Address - Country:US
Mailing Address - Phone:470-282-3268
Mailing Address - Fax:470-268-7957
Practice Address - Street 1:2406 ATHERHOLT RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2148
Practice Address - Country:US
Practice Address - Phone:434-846-3200
Practice Address - Fax:434-846-3436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004953029Medicaid