Healthcare Provider Details

I. General information

NPI: 1417696063
Provider Name (Legal Business Name): MARIE'S PERSONAL HOME CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

5205 BUENA VISTA RD
COLUMBUS GA
31907-5164
US

IV. Provider business mailing address

204 DUPONT CT
MCDONOUGH GA
30252-5844
US

V. Phone/Fax

Practice location:
  • Phone: 706-615-1037
  • Fax:
Mailing address:
  • Phone: 478-918-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MARIE BRUDENT
Title or Position: OWNER
Credential:
Phone: 706-615-1037