1710134267 NPI number — TENDER LOVING CARE HEALTH CARE SERVICES OF GEORGIA, L.L.C.

Table of content: (NPI 1710134267)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710134267 NPI number — TENDER LOVING CARE HEALTH CARE SERVICES OF GEORGIA, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TENDER LOVING CARE HEALTH CARE SERVICES OF GEORGIA, L.L.C.
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:
1710134267
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3854 AMERICAN WAY
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70816-4013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-292-2031
Provider Business Mailing Address Fax Number:
225-295-9678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2314 SULLIVAN RD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
COLLEGE PARK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30337-6306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-684-1932
Provider Business Practice Location Address Fax Number:
404-763-1610
Provider Enumeration Date:
08/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KUSSEROW
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
225-292-2031

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  060-286 , 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: 000281905H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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