NPIMap

Organization Active NPI

Providence SNF Operator LLC

  • Skilled Nursing Facility
  • Thomaston, GA
National Provider Identifier
1114448271
Registry record updated Jul 21, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
PROVIDENCE SNF OPERATOR LLC
Practice address
1011 S Green St
Thomaston, GA 30286-4643
Phone
(706) 647-6693
Fax
(706) 648-9255
NPI assigned
Jun 29, 2017
Organization subpart
No

Authorized official

NPPES NPI Registry
Name
Bruce E Wertheim
Title
Manager
Phone
(813) 347-9888

Facilities with the same owner 9

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

Care Compare: Nursing home

Medicare Care Compare
Listed as
Providence HealthcareCCN 115484
Overall star rating
2 of 5
Health inspections
1 of 5
Staffing
1 of 5
Quality measures
5 of 5
Type
Medicare and Medicaid
Ownership
For profit - Individual
Certified
Oct 1, 1989
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
11074.6 residents per day on average
Chain
Beacon Health Management11 facilities in the chain
Abuse citation
Cited for abuse (Care Compare abuse icon)
Penalties (3 years)
1Fines totaling $0

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
11D2165830Providence SNF Operator, LLC1011 South Green Street, Thomaston, GA 30286Certificate of waiverMay 6, 2027

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Skilled nursing facility certification: CCN 115484

Medicare enrollment files
Legal name
PROVIDENCE SNF OPERATOR LLC
Doing business as
PROVIDENCE HEALTHCARE
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Oct 1, 1989
Last certification
Feb 25, 2024
Beds
110
Ownership / control type
Individual
Multi-facility organization
Beacon LLC
Organization structure
LLCProprietary
Incorporated
Jun 6, 2017 in FL
Enrollment address
1011 S Green St
Thomaston, GA 30286-4643
Nursing home name
PROVIDENCE HEALTHCARE
Affiliated entity
BEACON HEALTH MANAGEMENT

All disclosed owners & managing parties 4

Medicare enrollment files

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Elisa Holiday Individual W-2 Managing EmployeeAdministrator Mar 14, 2022
Bruce E Wertheim Individual 5% Or Greater Indirect Ownership Interest Sep 1, 2017 100%
Operational/Managerial ControlManager Sep 1, 2017 100%
PWW Healthcare, LLC Organization, Tampa, FL LLC, For-profit 5% Or Greater Direct Ownership Interest Sep 1, 2017 100%
Beacon Health Management LLC Organization, Tampa, FL LLC, Management services company, For-profit Operational/Managerial Control Sep 1, 2017 100%

Medicare enrollment records 1

Medicare enrollment files
Enrollment IDStateProvider typePAC IDDetails
O20171213002392 GA Part a Provider - Skilled Nursing Facility 3779841143 Practice locations: Thomaston, GA

National Provider Directory

National Provider Directory

Specialties & licenses 1

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X GA Primary

Addresses

NPPES NPI Registry

Primary practice location

1011 S Green St
Thomaston, GA 30286-4643

Mailing address

1011 S Green St
Thomaston, GA 30286-4643
Phone (706) 647-6693

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Jul 21, 2022.

{
    "created_epoch": "1498694400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1114448271",
    "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 SNF OPERATOR LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-06-29",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "WERTHEIM",
        "authorized_official_first_name": "BRUCE",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "813-347-9888"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "GA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Thomaston, GA

Sources for this page

Verify at the official NPI Registry.