Healthcare Provider Details

I. General information

NPI: 1750763132
Provider Name (Legal Business Name): PRIMARY MEDICAL HOMECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2015
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 WINDY HILL RD SE SUITE 206
MARIETTA GA
30067-8644
US

IV. Provider business mailing address

2480 WINDY HILL RD SE SUITE 206
MARIETTA GA
30067-8644
US

V. Phone/Fax

Practice location:
  • Phone: 855-525-1000
  • Fax: 855-525-1056
Mailing address:
  • Phone: 855-525-1000
  • Fax: 855-525-1056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number033-R-1687
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberCN0028882028
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number68372
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License NumberCN0028882028
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number StateGA

VIII. Authorized Official

Name: DR. R. COSTON
Title or Position: CEO
Credential: PSY.D/PH.D
Phone: 855-525-1000