Healthcare Provider Details

I. General information

NPI: 1063712487
Provider Name (Legal Business Name): GLORY PERSONAL CARE HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2010
Last Update Date: 11/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 PACES LNDG
COVINGTON GA
30016-4167
US

IV. Provider business mailing address

90 PACES LNDG
COVINGTON GA
30016-4167
US

V. Phone/Fax

Practice location:
  • Phone: 678-432-8818
  • Fax:
Mailing address:
  • Phone: 678-432-8818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License NumberRN 188675
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberRN 188675
License Number StateGA

VIII. Authorized Official

Name: MRS. SYVIS A RODGERS
Title or Position: DIRECTOR
Credential:
Phone: 678-342-8818