Provider Demographics
NPI:1609070853
Name:SOVEREIGN HEALTHCARE OF BUCHANAN, LLC
Entity type:Organization
Organization Name:SOVEREIGN HEALTHCARE OF BUCHANAN, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:R.
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:CRONQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-574-2100
Mailing Address - Street 1:5887 GLENRIDGE DR NE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5574
Mailing Address - Country:US
Mailing Address - Phone:404-574-2100
Mailing Address - Fax:404-574-2105
Practice Address - Street 1:144 DEPOT ST
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:GA
Practice Address - Zip Code:30113-5216
Practice Address - Country:US
Practice Address - Phone:770-646-5512
Practice Address - Fax:770-646-5591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-071-1896314000000X
GA1-071-1897314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000142722AMedicaid
GA115587Medicare Oscar/Certification