Healthcare Provider Details

I. General information

NPI: 1093539686
Provider Name (Legal Business Name): AMPLIFYED HOLDINGS CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2882 CHURCH ST
EAST POINT GA
30344-3254
US

IV. Provider business mailing address

2882 CHURCH ST
EAST POINT GA
30344-3254
US

V. Phone/Fax

Practice location:
  • Phone: 404-692-8860
  • Fax:
Mailing address:
  • Phone: 404-692-8860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: TACQUORA LASHAE MIXON
Title or Position: MANAGER
Credential: CMA, CNA
Phone: 404-998-6903