Healthcare Provider Details

I. General information

NPI: 1376777482
Provider Name (Legal Business Name): MALIBU HEALTH CARE AGENCY, INC,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 05/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 HIGHWAY 213
COVINGTON GA
30014-7460
US

IV. Provider business mailing address

24 HIGHWAY 213
COVINGTON GA
30014-7460
US

V. Phone/Fax

Practice location:
  • Phone: 770-873-6303
  • Fax:
Mailing address:
  • Phone: 770-873-6303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number107-R-0357
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number107-R-0357
License Number StateGA

VIII. Authorized Official

Name: MARIE MARTHE PIERRE
Title or Position: ADMINISTRATOR/RN
Credential:
Phone: 770-873-6303