Healthcare Provider Details

I. General information

NPI: 1790256931
Provider Name (Legal Business Name): CHANGE OF LIFE COMPANION HOMECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 12/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 TOPAZ TRAIL PEACHTREE CITY
FAYETTEVILLE GA
30269
US

IV. Provider business mailing address

P.O. BOX 87242
COLLEGE PARK GA
30337
US

V. Phone/Fax

Practice location:
  • Phone: 404-307-7223
  • Fax:
Mailing address:
  • Phone: 404-307-7223
  • 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 Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MRS. NATASHA D YVETTE DUNN
Title or Position: ADMINISTRATOR DIRECTOR (OWNER)
Credential:
Phone: 404-307-7223