Provider Demographics
NPI:1194854638
Name:AZALEALAND NURSING HOME, INC.
Entity type:Organization
Organization Name:AZALEALAND NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:VONWALDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-354-2752
Mailing Address - Street 1:2040 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-2226
Mailing Address - Country:US
Mailing Address - Phone:912-354-2752
Mailing Address - Fax:912-352-2038
Practice Address - Street 1:2040 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2226
Practice Address - Country:US
Practice Address - Phone:912-354-2752
Practice Address - Fax:912-352-2038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10251060314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA115534Medicare Oscar/Certification