Healthcare Provider Details

I. General information

NPI: 1922425396
Provider Name (Legal Business Name): CORE INDEPENDENCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2014
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 GEORGE BUSBEE PKWY NW
KENNESAW GA
30144-0800
US

IV. Provider business mailing address

7220 SCOTSHIRE WAY
CUMMING GA
30040-7396
US

V. Phone/Fax

Practice location:
  • Phone: 678-206-6201
  • Fax:
Mailing address:
  • Phone: 954-816-3130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT005325
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT005289
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberOT005289
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberOT005289
License Number StateGA

VIII. Authorized Official

Name: MRS. JESSICA NAGY
Title or Position: OWNER
Credential: OT
Phone: 954-816-3130