Healthcare Provider Details

I. General information

NPI: 1962245142
Provider Name (Legal Business Name): MIND BODY AND SOUL HOMECARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 HANK AARON DR SW APT 5090
ATLANTA GA
30312-2889
US

IV. Provider business mailing address

565 HANK AARON DR SW APT 5090
ATLANTA GA
30312-2889
US

V. Phone/Fax

Practice location:
  • Phone: 404-839-2107
  • Fax:
Mailing address:
  • Phone: 404-839-2107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State

VIII. Authorized Official

Name: KALIA C LUCAS-SMITH
Title or Position: NURSE
Credential:
Phone: 404-839-2107