Provider Demographics
NPI:1255604559
Name:GORDAN OAKS AT GREYSTOKE LLC
Entity type:Organization
Organization Name:GORDAN OAKS AT GREYSTOKE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:WINGET
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:478-994-3669
Mailing Address - Street 1:105 PATROL RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:FORSYTH
Mailing Address - State:GA
Mailing Address - Zip Code:31029-1800
Mailing Address - Country:US
Mailing Address - Phone:478-994-3669
Mailing Address - Fax:478-994-3664
Practice Address - Street 1:3151A KNOLLWOOD DR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36693-2745
Practice Address - Country:US
Practice Address - Phone:251-661-7608
Practice Address - Fax:251-602-9146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-16
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4757990SMedicaid
015463Medicare Oscar/Certification