Healthcare Provider Details

I. General information

NPI: 1851155832
Provider Name (Legal Business Name): GEORGIA MOBILE HEALTHCARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2024
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 HILL LN
ELLENWOOD GA
30294-2805
US

IV. Provider business mailing address

153 HILL LN
ELLENWOOD GA
30294-2805
US

V. Phone/Fax

Practice location:
  • Phone: 770-453-2045
  • Fax: 770-264-4811
Mailing address:
  • Phone: 770-453-2045
  • Fax: 770-264-4811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number
License Number State

VIII. Authorized Official

Name: LAKESHA CHANDLER
Title or Position: OWNER
Credential:
Phone: 770-453-2045