Provider Demographics
NPI:1215112255
Name:LAUREL BAYE HEALTHCARE OF LAKE LANIER, LLC
Entity type:Organization
Organization Name:LAUREL BAYE HEALTHCARE OF LAKE LANIER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KYLIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:GRIECO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-216-6800
Mailing Address - Street 1:2451 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-2418
Mailing Address - Country:US
Mailing Address - Phone:770-614-2800
Mailing Address - Fax:770-932-5754
Practice Address - Street 1:2451 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-2418
Practice Address - Country:US
Practice Address - Phone:770-614-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2009-07-21
Deactivation Date:2008-08-18
Deactivation Code:
Reactivation Date:2008-09-24
Provider Licenses
StateLicense IDTaxonomies
GA10671659314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000140456AMedicaid
GA115600Medicare Oscar/Certification