LCS Brandon Wilde LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

License

1-036-2130 Issued in GA

Legal business name

LCS BRANDON WILDE LLC

Doing business as

The Pavilion at Brandon Wilde

Practice address

4275 Owens Rd
Evans, GA 30809

Phone

(706) 868-9800

NPI assigned

May 30, 2018

Organization subpart

No

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

Authorized official

Name

Diane C Bridgewater

Title

Manager of Managing Member

Phone

(515) 875-4500

Specialties & licenses 2

Addresses

Other names 1

• The Pavilion at Brandon Wilde Doing business as

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

{
    "created_epoch": "1527638400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1560902400000",
    "number": "1821580440",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4275 OWENS RD",
            "city": "EVANS",
            "state": "GA",
            "postal_code": "308093066",
            "telephone_number": "706-868-9800"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4275 OWENS RD",
            "city": "EVANS",
            "state": "GA",
            "postal_code": "30809",
            "telephone_number": "706-868-9800"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LCS BRANDON WILDE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-05-30",
        "last_updated": "2019-06-19",
        "status": "A",
        "authorized_official_last_name": "BRIDGEWATER",
        "authorized_official_first_name": "DIANE",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "MANAGER OF MANAGING MEMBER",
        "authorized_official_telephone_number": "515-875-4500"
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "GA",
            "license": "1-036-2130",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "The Pavilion at Brandon Wilde",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Jessica Marie Lanford, , DPT
• Larson Chiropractic,PC
• Eric John Larson, D.C.
• Adrian Nicole Lawrence, PHARM.D.
• Heather Layton
• Kristy Ledford, LPC
• Lauren Ledford
• Michelle A Lee Sing, MSW, LCSW
• Emily Lee, PHYSICIAN ASSISTANT
• Katherine B Lee, P.T.

• Skilled Nursing Facility in Evans, GA
• Providers in Evans, GA by specialty
• Skilled Nursing Facility in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 19, 2019; 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.