1083469092 NPI number — SUMMERFIELD PERSONAL CARE HOME LLC

Table of content: (NPI 1083469092)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083469092 NPI number — SUMMERFIELD PERSONAL CARE HOME LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMERFIELD 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:
1083469092
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12166 HIGHWAY 212
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINGTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30014-7876
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-600-6704
Provider Business Mailing Address Fax Number:
404-745-8410

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12166 HIGHWAY 212
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:
30014-7876
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-600-6704
Provider Business Practice Location Address Fax Number:
404-745-8410
Provider Enumeration Date:
04/22/2024

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBS
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
SNOW
Authorized Official Title or Position:
ADMINISTRATOR/PROVIDER
Authorized Official Telephone Number:
678-600-6704

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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