Healthcare Provider Details

I. General information

NPI: 1205418365
Provider Name (Legal Business Name): MILE STONE PERSONAL CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2021
Last Update Date: 04/27/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 ANDERSON AVE
FORT VALLEY GA
31030-4144
US

IV. Provider business mailing address

206 ANDERSON AVE
FORT VALLEY GA
31030-4144
US

V. Phone/Fax

Practice location:
  • Phone: 478-319-3158
  • Fax:
Mailing address:
  • Phone: 478-319-3158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. DIANE DAVIS
Title or Position: MANAGER
Credential:
Phone: 478-319-3158