1730439159 NPI number — COMFORT ZONE PERSONAL CARE HOME LLC

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 1730439159 NPI number — COMFORT ZONE PERSONAL CARE HOME LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMFORT ZONE PERSONAL CARE HOME 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:
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:
1730439159
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 STONE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCDONOUGH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30253-7267
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-712-9308
Provider Business Mailing Address Fax Number:
678-610-5498

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
485 FROG RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOCUST GROVE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30248-3505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-610-5498
Provider Business Practice Location Address Fax Number:
678-610-5498
Provider Enumeration Date:
09/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CLUKEY
Authorized Official First Name:
MARGARET
Authorized Official Middle Name:
WAIRIMU
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
770-712-9308

Provider Taxonomy Codes

  • Taxonomy code: 385HR2060X , with the licence number:  CLA001137 , 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: 181993856A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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