1255788436 NPI number — PEACHTREE HOSPICE OF GEORGIA, LLC

Table of content: (NPI 1255788436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255788436 NPI number — PEACHTREE HOSPICE OF GEORGIA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEACHTREE HOSPICE OF GEORGIA, 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:
BRIDGEWAY PALLIATIVE CARE
Provider Other Organization Name Type Code:
3
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:
1255788436
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1395 S MARIETTA PKWY SE
Provider Second Line Business Mailing Address:
BLDG 400 SUITE 116
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30067-4440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-932-6302
Provider Business Mailing Address Fax Number:
678-402-5246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
354 CORPORATE CENTER CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOCKBRIDGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30281-6360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-583-2269
Provider Business Practice Location Address Fax Number:
678-583-2270
Provider Enumeration Date:
05/18/2016

Additional Information

Authorized Official

Authorized Official Last Name:
RASMUSSEN
Authorized Official First Name:
GARY
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
678-932-6302

Provider Taxonomy Codes

  • Taxonomy code: 207RH0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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