Healthcare Provider Details

I. General information

NPI: 1467741710
Provider Name (Legal Business Name): ELITE HOME CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 04/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6804 BLACKSTONE PL
MABLETON GA
30126-5441
US

IV. Provider business mailing address

6804 BLACKSTONE PL
MABLETON GA
30126-5441
US

V. Phone/Fax

Practice location:
  • Phone: 678-699-4919
  • Fax: 678-402-7965
Mailing address:
  • Phone: 678-699-4919
  • Fax: 678-402-7965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number033013339
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number033013339
License Number StateGA

VIII. Authorized Official

Name: SHANTEL LONG
Title or Position: CEO
Credential:
Phone: 678-699-4919