1376151100 NPI number — ADVENT CARE SYSTEMS HOME CARE OF OCILLA, LLC.

Table of content: (NPI 1376151100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376151100 NPI number — ADVENT CARE SYSTEMS HOME CARE OF OCILLA, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVENT CARE SYSTEMS HOME CARE OF OCILLA, LLC.
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:
ADVENT CARE SYSTEMS OF OCILLA, LLC.
Provider Other Organization Name Type Code:
3
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:
1376151100
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 N IRWIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCILLA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31774-5007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-532-9308
Provider Business Mailing Address Fax Number:
229-299-9697

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 N IRWIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCILLA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31774-5007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-468-0646
Provider Business Practice Location Address Fax Number:
229-468-9300
Provider Enumeration Date:
07/17/2020

Additional Information

Authorized Official

Authorized Official Last Name:
TRETTIEN
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
912-532-9308

Provider Taxonomy Codes

  • Taxonomy code: 163WH0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: PHCP010926 . This is a "GA HFRD HOME CARE LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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