Healthcare Provider Details

I. General information

NPI: 1427605963
Provider Name (Legal Business Name): HEIDI ROSCOE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2019
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 COLTON DR
DALLAS GA
30132-2991
US

IV. Provider business mailing address

170 COLTON DR
DALLAS GA
30132-2991
US

V. Phone/Fax

Practice location:
  • Phone: 678-334-9890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: