Healthcare Provider Details

I. General information

NPI: 1033894068
Provider Name (Legal Business Name): PROUD LIFE HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10053 TARA GLYNN DR
HAMPTON GA
30228-6131
US

IV. Provider business mailing address

1700 NORTHSIDE DR NW STE A7
ATLANTA GA
30318-2695
US

V. Phone/Fax

Practice location:
  • Phone: 678-883-1407
  • Fax:
Mailing address:
  • Phone: 478-226-5568
  • 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 Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: MR. TONY M REESE
Title or Position: OWNER
Credential:
Phone: 281-818-9606