Healthcare Provider Details

I. General information

NPI: 1245057744
Provider Name (Legal Business Name): KOKUA COMMUNITY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

288 HIGH WAY 314 SUITE C
FAYETTEVILLE GA
30214
US

IV. Provider business mailing address

165 KEATON DR
FAYETTEVILLE GA
30215-2035
US

V. Phone/Fax

Practice location:
  • Phone: 470-352-0524
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: NIGEL GAUNTLETT
Title or Position: OWNER
Credential:
Phone: 470-352-0524