MEDICARE: HEALTHY GOALS HOMECARE LLC

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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1689472508
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHY GOALS HOMECARE LLC

Provider Business Mailing Address
First Line	:	4002 CREST RIDGE DR
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-8123
Country	:	US
Telephone Number	:	248-804-7303
Fax Number	:	404-885-8315

Provider Business Practice Location Address
First Line	:	4002 CREST RIDGE DR
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-8123
Country	:	US
Telephone Number	:	248-804-7303
Fax Number	:	404-885-8315

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	KANDASHA GLENN
Credential	:
Telephone Number	:	248-804-7303

Provider Enumeration Date	:	03/05/2025
Last Update Date	:	03/05/2025

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