MEDICARE: GARDENIA HOME CARE SERVICES, L.L.C

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	:	1821762535
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GARDENIA HOME CARE SERVICES, L.L.C

Provider Business Mailing Address
First Line	:	2420 WORTH AVE
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-3660
Country	:	US
Telephone Number	:	404-731-1882
Fax Number	:

Provider Business Practice Location Address
First Line	:	2420 WORTH AVE
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-3660
Country	:	US
Telephone Number	:	404-731-1882
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	THENETHONG SYBANGONE
Credential	:
Telephone Number	:	404-731-1882

Provider Enumeration Date	:	08/05/2021
Last Update Date	:	08/31/2021

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