Provider Demographics
NPI:1861586737
Name:COOSA NURSING ADK, LLC
Entity type:Organization
Organization Name:COOSA NURSING ADK, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/MIS
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:GROEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-964-8974
Mailing Address - Street 1:513 PINEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:AL
Mailing Address - Zip Code:35905-1803
Mailing Address - Country:US
Mailing Address - Phone:256-492-5350
Mailing Address - Fax:
Practice Address - Street 1:513 PINEVIEW AVE
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:AL
Practice Address - Zip Code:35905-1803
Practice Address - Country:US
Practice Address - Phone:256-492-5350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12535314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4753160SMedicaid
AL015174Medicare Oscar/Certification