Healthcare Provider Details

I. General information

NPI: 1033689336
Provider Name (Legal Business Name): POST ACUTE CARE LEADERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 PINE KNOLL DR
CARROLLTON GA
30117-2451
US

IV. Provider business mailing address

925 N POINT PKWY STE 425
ALPHARETTA GA
30005-5200
US

V. Phone/Fax

Practice location:
  • Phone: 678-593-3332
  • Fax: 678-868-1584
Mailing address:
  • Phone: 678-593-3332
  • Fax: 678-868-1584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TYLER JUSTISS
Title or Position: CONTROLLER
Credential:
Phone: 678-593-3332