Providence Health and Rehabilitation Center, Inc.

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

License

1-145-1868 Issued in GA

Legal business name

PROVIDENCE HEALTH AND REHABILITATION CENTER, INC.

Practice address

1011 S Green St
Thomaston, GA 30286-4643

Phone

(706) 647-6693

Fax

(706) 648-9255

NPI assigned

May 26, 2006

Organization subpart

Yes

Parent organization

PROHEALTH RESOURCE GROUP, INC.As reported in NPPES

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

Authorized official

Name

Mr. Richard E. Fallaw Sr.

Title

President

Phone

(229) 268-7510

Specialties & licenses 1

Addresses

Other identifiers 2

Part of

Prohealth Resource Group Inc

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

{
    "created_epoch": "1148601600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1191456000000",
    "number": "1083660120",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1011 S GREEN ST",
            "city": "THOMASTON",
            "state": "GA",
            "postal_code": "302864643",
            "telephone_number": "706-647-6693",
            "fax_number": "706-648-9255"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1011 S GREEN ST",
            "city": "THOMASTON",
            "state": "GA",
            "postal_code": "302864643",
            "telephone_number": "706-647-6693",
            "fax_number": "706-648-9255"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH AND REHABILITATION CENTER, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROHEALTH RESOURCE GROUP, INC.",
        "enumeration_date": "2006-05-26",
        "last_updated": "2007-10-04",
        "status": "A",
        "authorized_official_last_name": "FALLAW",
        "authorized_official_first_name": "RICHARD",
        "authorized_official_middle_name": "E.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "229-268-7510",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Sr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "GA",
            "license": "1-145-1868",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS/BLUE SHIELD",
            "identifier": "51004538001",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00142612A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Brandy Pfeiffer
• Melanie Robin Phillips, PHARMD
• Andrea Ruth Pinnow, MSW, LCSW
• Practice Equity, LLC
• Angelic J Prather, D.C.
• Providence Post Acute LLC
• Providence SNF Operator LLC
• Kendra Latrice Raines, APRN
• Rayneb Medical
• Red Clay Ventures, LLC

• All providers in Thomaston, GA
• Skilled Nursing Facility in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 4, 2007; 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.