Healthcare Provider Details

I. General information

NPI: 1235955741
Provider Name (Legal Business Name):
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2024
Last Update Date: 11/29/2024
Certification Date: 11/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5889 WHEELER RIDGE RD
AUBURN GA
30011-3488
US

IV. Provider business mailing address

5889 WHEELER RIDGE RD
AUBURN GA
30011-3488
US

V. Phone/Fax

Practice location:
  • Phone: 678-294-2403
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: HELEN PETGRAVE
Title or Position: CEO
Credential:
Phone: 678-294-2403