Provider Demographics
NPI:1801056791
Name:PETLIN DIVERSIFIED SERVICES LLC
Entity type:Organization
Organization Name:PETLIN DIVERSIFIED SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:ANGELA
Authorized Official - Last Name:MBAH
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:770-595-8934
Mailing Address - Street 1:2817 LOST LAKES WAY
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-6018
Mailing Address - Country:US
Mailing Address - Phone:770-595-8934
Mailing Address - Fax:
Practice Address - Street 1:2817 LOST LAKES WAY
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-6018
Practice Address - Country:US
Practice Address - Phone:770-595-8934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN155427NP314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility