Healthcare Provider Details

I. General information

NPI: 1164092607
Provider Name (Legal Business Name): CELESTIAL PRIVATE HOMECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 CHAMBLEE TUCKER RD STE 100
CHAMBLEE GA
30341-4100
US

IV. Provider business mailing address

9442 S MAIN ST STE 107
JONESBORO GA
30236-6000
US

V. Phone/Fax

Practice location:
  • Phone: 770-626-3865
  • Fax: 770-626-3867
Mailing address:
  • Phone: 678-972-4191
  • Fax: 770-626-3867

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 Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: WHITNEY DAVIS
Title or Position: ADMINISTRATOR
Credential:
Phone: 770-626-3865