Provider Demographics
NPI:1598412199
Name:1304 WALNUT STREET OPERATIONS, LLC
Entity type:Organization
Organization Name:1304 WALNUT STREET OPERATIONS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:LEHNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-698-9040
Mailing Address - Street 1:1304 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:MS
Mailing Address - Zip Code:39367-2232
Mailing Address - Country:US
Mailing Address - Phone:601-735-9025
Mailing Address - Fax:601-735-2865
Practice Address - Street 1:1304 WALNUT ST
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:MS
Practice Address - Zip Code:39367-2232
Practice Address - Country:US
Practice Address - Phone:601-735-9025
Practice Address - Fax:601-735-2865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-04
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000230118Medicaid