Provider Demographics
NPI:1194917617
Name:LAKE OCONEE ASSISTED LIVING, LLC
Entity type:Organization
Organization Name:LAKE OCONEE ASSISTED LIVING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LILLIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:TRIPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-453-9055
Mailing Address - Street 1:107 E BROAD ST
Mailing Address - Street 2:P.O. BOX 1152
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30642-1337
Mailing Address - Country:US
Mailing Address - Phone:706-453-9055
Mailing Address - Fax:706-453-4156
Practice Address - Street 1:107 E BROAD ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-1337
Practice Address - Country:US
Practice Address - Phone:706-453-9055
Practice Address - Fax:706-453-4156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA0600X, 261QD1600X
GACLA0011423104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities