Healthcare Provider Details

I. General information

NPI: 1225712961
Provider Name (Legal Business Name): PHENOMENAL CARE SOLUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2023
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 COUNTRY WALK WAY SE APT A
CONYERS GA
30013-6765
US

IV. Provider business mailing address

2111 COUNTRY WALK WAY SE APT A
CONYERS GA
30013-6765
US

V. Phone/Fax

Practice location:
  • Phone: 404-789-4304
  • Fax:
Mailing address:
  • Phone: 404-789-4304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name: CANDICE LATRE WEBB
Title or Position: OWNER
Credential:
Phone: 404-789-4304