Provider Demographics
NPI:1992068670
Name:EDGEWOOD OF MONTICELLO
Entity type:Organization
Organization Name:EDGEWOOD OF MONTICELLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-468-7100
Mailing Address - Street 1:1178 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:GA
Mailing Address - Zip Code:31064-2111
Mailing Address - Country:US
Mailing Address - Phone:706-468-7100
Mailing Address - Fax:706-468-7090
Practice Address - Street 1:1178 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:GA
Practice Address - Zip Code:31064-2111
Practice Address - Country:US
Practice Address - Phone:706-468-7100
Practice Address - Fax:706-468-7090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA079020011310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility