1861994295 NPI number — BELOVED CARE CORPORATION

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 1861994295 NPI number — BELOVED CARE CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BELOVED CARE CORPORATION
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:
6
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:
1861994295
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2466 QUENTIN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30236-5255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-775-0949
Provider Business Mailing Address Fax Number:
770-788-1740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1119 CHURCH ST SE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30014-2318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-788-1739
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/01/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WALKER
Authorized Official First Name:
JERMAINE
Authorized Official Middle Name:
LADYRELL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
404-775-0949

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X , with the licence number:  107-R-1176 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385H00000X , with the licence number: 107-R-1176 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 374U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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