# LAKE OCONEE ASSISTED LIVING, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Kingdom Care Service Center
- **Organization subpart:** No

## Provider details

- **NPI number:** 1194917617
- **Authorized official:** LILLIE R. TRIPP (CONTROLLING MANAGER)
- **Authorized official phone:** (706) 453-9055

## Contact information

- **Practice address:** 107 E BROAD ST, GREENSBORO, GA 30642-1337
- **Practice address phone:** (706) 453-9055
- **Practice address fax:** (706) 453-4156
- **Mailing address:** 107 E BROAD ST, P.O. BOX 1152, GREENSBORO, GA 30642-1337
- **Mailing address phone:** (706) 453-9055
- **Mailing address fax:** (706) 453-4156

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QA0600X | Adult Day Care Clinic/Center | — | NULL | — |
| 261QD1600X | Developmental Disabilities Clinic/Center | — | NULL | — |
| 3104A0630X | Assisted Living Facility (Behavioral Disturbances) | CLA001142 | GA | Yes |

## Other

- **Enumeration date:** 08/17/2007
- **Last updated:** 07/21/2022