Provider Demographics
NPI:1992958474
Name:SKYLAND MANOR PCH
Entity type:Organization
Organization Name:SKYLAND MANOR PCH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:HUGH
Authorized Official - Middle Name:HENDERSON
Authorized Official - Last Name:GREENIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-269-9764
Mailing Address - Street 1:22546 MURDOCK AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-2729
Mailing Address - Country:US
Mailing Address - Phone:646-269-9764
Mailing Address - Fax:718-465-1813
Practice Address - Street 1:3505 SKYLAND DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-8962
Practice Address - Country:US
Practice Address - Phone:770-985-3400
Practice Address - Fax:770-985-3425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061-01-329-1310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility