Healthcare Provider Details

I. General information

NPI: 1952531956
Provider Name (Legal Business Name): MIMS CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2009
Last Update Date: 07/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1589 MIMS ST SW
ATLANTA GA
30314-2255
US

IV. Provider business mailing address

2103 JOCKEY HOLLOW DR NW
KENNESAW GA
30152-3169
US

V. Phone/Fax

Practice location:
  • Phone: 404-569-1041
  • Fax:
Mailing address:
  • Phone: 404-569-1041
  • Fax: 770-422-5929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number060-01-360-9
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number060-01-360-9
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number060-01-360-9
License Number StateGA

VIII. Authorized Official

Name: OLUBISI EMMANUEL OLUYEMI
Title or Position: C.E.O
Credential: PH.D
Phone: 404-569-1041