Healthcare Provider Details

I. General information

NPI: 1063424752
Provider Name (Legal Business Name): GEORGIA IN HOME SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 ZELKOVA DR
FAYETTEVILLE GA
30215-2528
US

IV. Provider business mailing address

155 ZELKOVA DR
FAYETTEVILLE GA
30215-2528
US

V. Phone/Fax

Practice location:
  • Phone: 678-817-7338
  • Fax:
Mailing address:
  • Phone: 678-817-7338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number056-R-0260
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number056-R-0260
License Number StateGA

VIII. Authorized Official

Name: MS. SHANTEL MARIE FORSTALL
Title or Position: ADMINISTRATOR
Credential: MSW
Phone: 678-817-7338