Provider Demographics
NPI:1770036030
Name:TRACES OF TIGER I
Entity type:Organization
Organization Name:TRACES OF TIGER I
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MB
Authorized Official - Prefix:MS
Authorized Official - First Name:CARLIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-746-6571
Mailing Address - Street 1:382 BRIDGE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TIGER
Mailing Address - State:GA
Mailing Address - Zip Code:30576-2211
Mailing Address - Country:US
Mailing Address - Phone:706-782-6208
Mailing Address - Fax:706-782-5019
Practice Address - Street 1:382 BRIDGE CREEK RD
Practice Address - Street 2:
Practice Address - City:TIGER
Practice Address - State:GA
Practice Address - Zip Code:30576-2211
Practice Address - Country:US
Practice Address - Phone:706-782-6208
Practice Address - Fax:706-782-5019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA119030011310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility