Healthcare Provider Details

I. General information

NPI: 1538438809
Provider Name (Legal Business Name): NELL'S PERSONAL CARE HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2011
Last Update Date: 12/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8990 STERLING RIDGE LN
JONESBORO GA
30238-4659
US

IV. Provider business mailing address

8990 STERLING RIDGE LN
JONESBORO GA
30238-4659
US

V. Phone/Fax

Practice location:
  • Phone: 770-471-2287
  • Fax: 770-471-6622
Mailing address:
  • Phone: 770-471-2287
  • Fax: 770-471-6622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number031012541
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number031012541
License Number StateGA

VIII. Authorized Official

Name: MR. CLIFFORD L. JACKSON
Title or Position: CEO
Credential:
Phone: 770-471-2287