Healthcare Provider Details

I. General information

NPI: 1760924278
Provider Name (Legal Business Name): DIVERSIFIED PERSONAL HOME CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2016
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 MCINTOSH PLACE DR
FAYETTEVILLE GA
30214-7318
US

IV. Provider business mailing address

145 MCINTOSH PLACE DR
FAYETTEVILLE GA
30214-7318
US

V. Phone/Fax

Practice location:
  • Phone: 404-993-1270
  • 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 Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number056-R-1338
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number056-R-1338
License Number StateGA

VIII. Authorized Official

Name: ADESOLA OSILAJA
Title or Position: OWNER/CEO
Credential:
Phone: 404-993-1270