Provider Demographics
NPI:1871589580
Name:CHRISTIAN CITY CONVALESCENT CENTER
Entity type:Organization
Organization Name:CHRISTIAN CITY CONVALESCENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:R
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-703-2611
Mailing Address - Street 1:7300 LESTER RD
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291-2328
Mailing Address - Country:US
Mailing Address - Phone:770-964-3301
Mailing Address - Fax:
Practice Address - Street 1:7300 LESTER RD
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:GA
Practice Address - Zip Code:30291-2328
Practice Address - Country:US
Practice Address - Phone:770-964-3301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANHA004005314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA71-00122OtherEVERCARE/UNITED HEALTH CA
GA71-00122OtherEVERCARE/UNITED HEALTH CA