1457583718 NPI number — SUNCREST HOME HEALTH OF SOUTH GA, INC.

Table of content: (NPI 1457583718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457583718 NPI number — SUNCREST HOME HEALTH OF SOUTH GA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNCREST HOME HEALTH OF SOUTH GA, 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:
1457583718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 51266
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70505-1266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-233-1307
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1221 W 4TH ST STE 7
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ADEL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31620-2906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-896-8177
Provider Business Practice Location Address Fax Number:
229-296-7880
Provider Enumeration Date:
08/19/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PROFFITT
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
SECRETARY / TREASURER
Authorized Official Telephone Number:
337-233-1307

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  037-101 , 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: 00887983A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com