MEDICARE: OLIVE HOME CARE SERVICES, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	031-R-0047	GA

General Provider Information

NPI Number	:	1063896009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLIVE HOME CARE SERVICES, INC

Provider Business Mailing Address
First Line	:	808 COMMERCE BLVD
Second Line	:	E
City	:	RIVERDALE
State	:	GA
Zip	:	30296-7192
Country	:	US
Telephone Number	:	770-997-8949
Fax Number	:

Provider Business Practice Location Address
First Line	:	808 COMMERCE BLVD
Second Line	:	E
City	:	RIVERDALE
State	:	GA
Zip	:	30296-7192
Country	:	US
Telephone Number	:	770-997-8949
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	GANIYU KASUMU
Credential	:
Telephone Number	:	770-997-8949

Provider Enumeration Date	:	07/18/2015
Last Update Date	:	07/18/2015

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Directions to “OLIVE HOME CARE SERVICES, INC ” Practice Location

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