Provider Demographics
NPI:1861763195
Name:FALCON CREST MANOR, LLC
Entity type:Organization
Organization Name:FALCON CREST MANOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:KINDELIN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:478-456-4758
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:31031-0100
Mailing Address - Country:US
Mailing Address - Phone:478-628-1126
Mailing Address - Fax:478-628-1026
Practice Address - Street 1:111 EPPS ST
Practice Address - Street 2:
Practice Address - City:GORDON
Practice Address - State:GA
Practice Address - Zip Code:31031-3805
Practice Address - Country:US
Practice Address - Phone:478-628-1126
Practice Address - Fax:478-628-1026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA158030011310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility