Healthcare Provider Details

I. General information

NPI: 1447426093
Provider Name (Legal Business Name): MINERS CREEK PERSONAL CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2008
Last Update Date: 05/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4227 MINERS CREEK RD
LITHONIA GA
30038-3814
US

IV. Provider business mailing address

5506 STONELEIGH CT
STONE MOUNTAIN GA
30088-3433
US

V. Phone/Fax

Practice location:
  • Phone: 404-641-6275
  • Fax:
Mailing address:
  • Phone: 404-641-6275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number044017069
License Number StateGA

VIII. Authorized Official

Name: MS. VIRGINIA MAE THOMPSON
Title or Position: OWNER ADMINISTRATOR
Credential:
Phone: 404-641-6275