1255345534 NPI number — PUBLIC HEALTH PERSONAL SUPPORT SERVICES, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255345534 NPI number — PUBLIC HEALTH PERSONAL SUPPORT SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUBLIC HEALTH PERSONAL SUPPORT SERVICES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255345534
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3284
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALDOSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31604-3284
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-253-1164
Provider Business Mailing Address Fax Number:
229-253-1151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1811 GREEN CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALDOSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31602-2734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-253-1164
Provider Business Practice Location Address Fax Number:
229-253-1151
Provider Enumeration Date:
07/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RETTERBUSH
Authorized Official First Name:
DENISE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
229-253-1067

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  092-R-002 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00621013A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00056845H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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