Healthcare Provider Details

I. General information

NPI: 1285480962
Provider Name (Legal Business Name): 123 GA HOME HEALTHCARE, LLLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 09/17/2026
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

767 NORTH AVE
JONESBORO GA
30236-2232
US

IV. Provider business mailing address

767 NORTH AVE
JONESBORO GA
30236-2232
US

V. Phone/Fax

Practice location:
  • Phone: 678-304-2118
  • Fax: 478-202-9464
Mailing address:
  • Phone: 678-304-2118
  • Fax: 478-202-9464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MR. DERRICK WHISBY
Title or Position: CEO
Credential:
Phone: 470-554-6864