1093027641 NPI number — GEORGIA COMMUNITY PRIVATE HOME CARE SERVICES

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 1093027641 NPI number — GEORGIA COMMUNITY PRIVATE HOME CARE SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA COMMUNITY PRIVATE HOME CARE SERVICES
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:
1093027641
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5644 HUNTERS CROSSING CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITHONIA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30038-1529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-987-7053
Provider Business Mailing Address Fax Number:
770-987-5571

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5644 HUNTERS CROSSING CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITHONIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30038-1529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-987-7053
Provider Business Practice Location Address Fax Number:
770-987-5571
Provider Enumeration Date:
07/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
AKINTOMIDE
Authorized Official First Name:
IYABO
Authorized Official Middle Name:
OLATUNDE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
770-987-7053

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X , with the licence number:  044-R-0497 , 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: 207881949A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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