Provider Demographics
NPI:1053463786
Name:ADK JEFFERSONVILLE OPERATOR, LLC
Entity type:Organization
Organization Name:ADK JEFFERSONVILLE OPERATOR, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP MIS
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:GROEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-964-8974
Mailing Address - Street 1:113 SPRING VALLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31044-9301
Mailing Address - Country:US
Mailing Address - Phone:478-945-2520
Mailing Address - Fax:478-945-2525
Practice Address - Street 1:113 SPRING VALLEY DRIVE
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:31044-9301
Practice Address - Country:US
Practice Address - Phone:478-945-2520
Practice Address - Fax:478-945-2525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11431882314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00282235AMedicaid
GA115413Medicare ID - Type Unspecified