Providence Place LLC

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

Legal business name

PROVIDENCE PLACE LLC

Doing business as

Cotton Grove Estate

Practice address

249 Joe Naia Rd
Jesup, GA 31545-4112

Phone

(912) 415-1313

NPI assigned

Aug 31, 2022

Organization subpart

Yes

Parent organization

PROVIDENCE PLACE LLCAs reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Stephanie Chadwick

Title

Owner

Phone

(912) 415-1313

Specialties & licenses 3

Addresses

Other names 1

• Cotton Grove Estate Doing business as

Electronic endpoints 1

Part of

Providence Place LLC

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1661904000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1661904000000",
    "number": "1063132876",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "249 JOE NAIA RD",
            "city": "JESUP",
            "state": "GA",
            "postal_code": "315454112",
            "telephone_number": "912-415-1313"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "249 JOE NAIA RD",
            "city": "JESUP",
            "state": "GA",
            "postal_code": "315454112",
            "telephone_number": "912-415-1313"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE PLACE LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROVIDENCE PLACE LLC",
        "enumeration_date": "2022-08-31",
        "last_updated": "2022-08-31",
        "certification_date": "2022-08-31",
        "status": "A",
        "authorized_official_last_name": "CHADWICK",
        "authorized_official_first_name": "STEPHANIE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "912-415-1313"
    },
    "taxonomies": [
        {
            "code": "251C00000X",
            "taxonomy_group": "",
            "desc": "Day Training, Developmentally Disabled Services",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "320600000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://cottongroveestate.com",
            "affiliation": "N",
            "endpointDescription": "website",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "249 Joe Naia Rd",
            "city": "Jesup",
            "state": "GA",
            "country_code": "US",
            "postal_code": "315454112",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Cotton Grove Estate",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Taylor Jordan Polander, MD
• Alyson Leigh Pond, LCSW
• Mia Popkin, MHS, OTR/L
• Brenda Joyce Poythress, NP-C
• Kali Sarah Price
• Robert Allen Pumpelly IV, MD
• Breanna Pye
• Justin Garrett Pye, PT
• Rabessler MD PC
• Randy Lentz MD

• Assisted Living Facility in Jesup, GA
• Providers in Jesup, GA by specialty
• Assisted Living Facility in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 31, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.