Healthcare Provider Details

I. General information

NPI: 1588991236
Provider Name (Legal Business Name): ANTOINETTE FULLER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2024 REGISTRY DR
HAMPTON GA
30228-6396
US

IV. Provider business mailing address

2024 REGISTRY DR
HAMPTON GA
30228-6396
US

V. Phone/Fax

Practice location:
  • Phone: 678-519-0131
  • Fax:
Mailing address:
  • Phone: 678-519-0131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code315D00000X
TaxonomyInpatient Hospice
License Number
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number StateGA

VIII. Authorized Official

Name: MISS ANTOINETTE FULLER
Title or Position: OWNER OPERATOR
Credential: OWNER
Phone: 678-519-0131