1083996292 NPI number — TERRELL'S PERSONAL CARE HOME, 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 1083996292 NPI number — TERRELL'S PERSONAL CARE HOME, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TERRELL'S PERSONAL CARE HOME, 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:
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:
1083996292
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
126 BARRINGTON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30605-3580
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-338-5091
Provider Business Mailing Address Fax Number:
866-615-7091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5100 ATLANTA HWY
Provider Second Line Business Practice Location Address:
5150 ATLANTA HIGHWAY
Provider Business Practice Location Address City Name:
BOGART
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30622-2109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-338-5091
Provider Business Practice Location Address Fax Number:
866-615-7091
Provider Enumeration Date:
09/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
TERRELL-MOON
Authorized Official First Name:
ANDRICK
Authorized Official Middle Name:
Authorized Official Title or Position:
PROGRAM MANAGER
Authorized Official Telephone Number:
706-338-5091

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , 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: 233656728A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 404716841B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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