Healthcare Provider Details

I. General information

NPI: 1497646582
Provider Name (Legal Business Name): GREEN HEARTS ADULT DAY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2025
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 RYAN TRL
DALLAS GA
30157-1078
US

IV. Provider business mailing address

5 RYAN TRL
DALLAS GA
30157-1078
US

V. Phone/Fax

Practice location:
  • Phone: 470-685-0514
  • Fax:
Mailing address:
  • Phone: 470-685-0514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. LATOYA BROWN NICKLES
Title or Position: OWNER
Credential:
Phone: 470-685-0514