Healthcare Provider Details

I. General information

NPI: 1679958003
Provider Name (Legal Business Name): N/A AT PRESENT TIME, WILL BE WORKING CONTRACTPRIVATEDUTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2015
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401A BOULEVARD 401ABOULEVARD
LAGRANGE GA
30240-3009
US

IV. Provider business mailing address

401A BOULEVARD 401ABOULEVARD
LAGRANGE GA
30240-3009
US

V. Phone/Fax

Practice location:
  • Phone: 706-333-9369
  • Fax:
Mailing address:
  • Phone: 706-333-9369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberCN0000047840
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberCN0000047840
License Number StateAL

VIII. Authorized Official

Name: MISS LISA POTTS
Title or Position: CNA
Credential: CERTIFIED NURSING AS
Phone: 706-333-9369