Provider Demographics
NPI:1124146014
Name:THE POTTER'S HOUSE OF WRIGHTSVILLE
Entity type:Organization
Organization Name:THE POTTER'S HOUSE OF WRIGHTSVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEATRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:478-864-0400
Mailing Address - Street 1:312 N MARCUS ST
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31096-1012
Mailing Address - Country:US
Mailing Address - Phone:478-864-0400
Mailing Address - Fax:478-864-0442
Practice Address - Street 1:312 N MARCUS ST
Practice Address - Street 2:
Practice Address - City:WRIGHTSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31096-1012
Practice Address - Country:US
Practice Address - Phone:478-864-0400
Practice Address - Fax:478-864-0442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0791491BMedicaid
GA0791491AMedicaid