Healthcare Provider Details

I. General information

NPI: 1396409918
Provider Name (Legal Business Name): STELLA GROVE HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2021
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 THOROUGHBRED LN
EVANS GA
30809-4107
US

IV. Provider business mailing address

321 THOROUGHBRED LN
EVANS GA
30809-4107
US

V. Phone/Fax

Practice location:
  • Phone: 404-759-6625
  • Fax:
Mailing address:
  • Phone: 404-759-6625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: DOMINIQUE DEVON STEWART
Title or Position: ADMINISTRATOR - OWNER
Credential:
Phone: 404-759-6625