Provider Demographics
NPI:1083660120
Name:PROVIDENCE HEALTH AND REHABILITATION CENTER, INC.
Entity type:Organization
Organization Name:PROVIDENCE HEALTH AND REHABILITATION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:FALLAW
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:229-268-7510
Mailing Address - Street 1:1011 S GREEN ST
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-4643
Mailing Address - Country:US
Mailing Address - Phone:706-647-6693
Mailing Address - Fax:706-648-9255
Practice Address - Street 1:1011 S GREEN ST
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-4643
Practice Address - Country:US
Practice Address - Phone:706-647-6693
Practice Address - Fax:706-648-9255
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROHEALTH RESOURCE GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-26
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-145-1868314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
51004538001OtherBLUE CROSS/BLUE SHIELD
GA00142612AMedicaid
11-5484Medicare ID - Type Unspecified