Healthcare Provider Details

I. General information

NPI: 1902059439
Provider Name (Legal Business Name): COLEMAN & STALLWORTH REAL ESTATE HOLDING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 06/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4363 AZALEA WALK
ELLENWOOD GA
30294-6552
US

IV. Provider business mailing address

4363 AZALEA WALK
ELLENWOOD GA
30294-6552
US

V. Phone/Fax

Practice location:
  • Phone: 404-244-3292
  • Fax: 404-244-3414
Mailing address:
  • Phone: 404-244-3292
  • Fax: 404-244-3414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number044--R-0499
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number044-R-0499
License Number StateGA

VIII. Authorized Official

Name: HENRY STALLWORTH
Title or Position: PRESIDENT
Credential:
Phone: 678-602-0183