Provider Demographics
NPI:1730573734
Name:HEALTHCARE AT COLLEGE PARK, LLC
Entity type:Organization
Organization Name:HEALTHCARE AT COLLEGE PARK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:WINGET
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:478-974-0006
Mailing Address - Street 1:1765 TEMPLE AVE
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30337-2736
Mailing Address - Country:US
Mailing Address - Phone:404-767-8609
Mailing Address - Fax:404-766-2957
Practice Address - Street 1:1765 TEMPLE AVE
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30337-2736
Practice Address - Country:US
Practice Address - Phone:404-767-8609
Practice Address - Fax:404-766-2957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000140654AMedicaid
115579Medicare Oscar/Certification