Provider Demographics
NPI:1154558690
Name:STEVENS PARK HEALTH AND REHABILITATION CENTER LLC
Entity type:Organization
Organization Name:STEVENS PARK HEALTH AND REHABILITATION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-737-0350
Mailing Address - Street 1:820 STEVENS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9251
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 STEVENS CREEK RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-9251
Practice Address - Country:US
Practice Address - Phone:478-621-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-11
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-121-1951314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003143404AMedicaid
GA003143404AMedicaid