Fireside-LTC, LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

Legal business name

FIRESIDE-LTC, LLC

Doing business as

Fireside House of Centralia

Practice address

1030 Martin Luther King Dr
Centralia, IL 62801-3002

Phone

(678) 522-2436

Fax

(770) 663-4539

NPI assigned

Oct 25, 2011

Last updated

Nov 10, 2011By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Mr. Daren G Douston

Title

Member Cfo

Phone

(678) 522-2436

Specialties & licenses 1

Addresses

Other names 1

• Fireside House of Centralia Doing business as

Locations

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

{
    "created_epoch": "1319500800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1320883200000",
    "number": "1346526134",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10945 STATE BRIDGE RD",
            "address_2": "SUITE 401-470",
            "city": "ALPHARETTA",
            "state": "GA",
            "postal_code": "300228164",
            "telephone_number": "678-522-2436",
            "fax_number": "770-663-4539"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1030 MARTIN LUTHER KING DR",
            "city": "CENTRALIA",
            "state": "IL",
            "postal_code": "628013002",
            "telephone_number": "678-522-2436",
            "fax_number": "770-663-4539"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FIRESIDE-LTC, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-10-25",
        "last_updated": "2011-11-10",
        "status": "A",
        "authorized_official_last_name": "DOUSTON",
        "authorized_official_first_name": "DAREN",
        "authorized_official_middle_name": "G",
        "authorized_official_title_or_position": "MEMBER CFO",
        "authorized_official_telephone_number": "678-522-2436",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Fireside House of Centralia",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Skilled Nursing Facility in Centralia, IL
• Providers in Centralia, IL by specialty
• Skilled Nursing Facility in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 10, 2011; 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.