Healthcare Provider Details

I. General information

NPI: 1417229873
Provider Name (Legal Business Name): CAUGAN WELLSPRING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2012
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4220 FOX DEN DR
DOUGLASVILLE GA
30135-4374
US

IV. Provider business mailing address

4220 FOX DEN DR
DOUGLASVILLE GA
30135-4374
US

V. Phone/Fax

Practice location:
  • Phone: 678-601-1507
  • Fax:
Mailing address:
  • Phone: 678-601-1507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number048-R-0935
License Number StateGA

VIII. Authorized Official

Name: MRS. DAWNETTE DENISE GANIGA
Title or Position: ADMINISTRATOR
Credential: MBA
Phone: 678-601-1507