Provider Demographics
NPI:1104398866
Name:UNIVERSITY EXTENDED CARE, INC
Entity type:Organization
Organization Name:UNIVERSITY EXTENDED CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR DECISION SUPPORT
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-828-2445
Mailing Address - Street 1:1005 HIGHWAY 88 N
Mailing Address - Street 2:
Mailing Address - City:KEYSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30816
Mailing Address - Country:US
Mailing Address - Phone:706-547-2591
Mailing Address - Fax:706-547-0492
Practice Address - Street 1:1005 HIGHWAY 88 N
Practice Address - Street 2:
Practice Address - City:KEYSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30816
Practice Address - Country:US
Practice Address - Phone:706-547-2591
Practice Address - Fax:706-547-0492
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY EXTENDED CARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000141655AMedicaid