Organization
FIRESIDE-LTC, LLC
Active
Other names
Fireside House of Centralia
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DAREN G DOUSTON (MEMBER CFO)
(678) 522-2436
Entity
Organization
Contact information
Practice address
1030 MARTIN LUTHER KING DR, CENTRALIA, IL 62801-3002
(678) 522-2436
(770) 663-4539
Mailing address
10945 STATE BRIDGE RD, SUITE 401-470, ALPHARETTA, GA 30022-8164
(678) 522-2436
(770) 663-4539
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
—
—
Other
Enumeration date
10/25/2011
Last updated
11/10/2011
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