Provider Demographics
NPI:1215153770
Name:GWENDOLYN WILKES RAINBOW CENTER
Entity type:Organization
Organization Name:GWENDOLYN WILKES RAINBOW CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:706-320-9012
Mailing Address - Street 1:2201 BUENA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-3121
Mailing Address - Country:US
Mailing Address - Phone:706-320-9012
Mailing Address - Fax:706-320-9021
Practice Address - Street 1:2201 BUENA VISTA RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-3121
Practice Address - Country:US
Practice Address - Phone:706-320-9012
Practice Address - Fax:706-320-9021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00070132BMedicaid