Healthcare Provider Details

I. General information

NPI: 1255715421
Provider Name (Legal Business Name): COLLABORATIVE PROFESSIONAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2015
Last Update Date: 10/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 CORNWALLIS WAY
FAYETTEVILLE GA
30214-1591
US

IV. Provider business mailing address

410 CORNWALLIS WAY
FAYETTEVILLE GA
30214-1591
US

V. Phone/Fax

Practice location:
  • Phone: 678-304-9787
  • Fax:
Mailing address:
  • Phone: 678-304-9787
  • 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 Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State

VIII. Authorized Official

Name: FELICITA WRIGHT
Title or Position: OWNER/DON
Credential:
Phone: 678-304-9787