Provider Demographics
NPI:1215919709
Name:MIONA GERIATRIC & DEMENTIA CENTER, LLC
Entity type:Organization
Organization Name:MIONA GERIATRIC & DEMENTIA CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-949-2270
Mailing Address - Street 1:201 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:IDEAL
Mailing Address - State:GA
Mailing Address - Zip Code:31041-6264
Mailing Address - Country:US
Mailing Address - Phone:478-949-2270
Mailing Address - Fax:
Practice Address - Street 1:201 POPLAR ST
Practice Address - Street 2:
Practice Address - City:IDEAL
Practice Address - State:GA
Practice Address - Zip Code:31041-6264
Practice Address - Country:US
Practice Address - Phone:478-949-2270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10941944314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA141578AMedicaid
GA141578AMedicaid