Healthcare Provider Details

I. General information

NPI: 1831491463
Provider Name (Legal Business Name): MEDI HOME THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2010
Last Update Date: 12/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1257 COMMERCIAL DR SW STE B
CONYERS GA
30094-5991
US

IV. Provider business mailing address

1257 COMMERCIAL DR SW STE B
CONYERS GA
30094-5991
US

V. Phone/Fax

Practice location:
  • Phone: 770-483-6393
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: JESSICA LANE
Title or Position: ADMINISTRATOR
Credential:
Phone: 770-483-6393