Healthcare Provider Details

I. General information

NPI: 1215614482
Provider Name (Legal Business Name): 1ST GWINNETT HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 07/25/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1743 CROSSWATERS CT
DACULA GA
30019-1729
US

IV. Provider business mailing address

35 FIRST ST STE 2
HOSCHTON GA
30548-2234
US

V. Phone/Fax

Practice location:
  • Phone: 612-396-4827
  • Fax:
Mailing address:
  • Phone: 770-318-7530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: LAURA NDINGWAN
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 612-396-4827