Healthcare Provider Details

I. General information

NPI: 1326223702
Provider Name (Legal Business Name): LIFE TIME HOME CARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2008
Last Update Date: 01/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

577 PINE VALLEY DR SUITE 200
POWDER SPRINGS GA
30127-6629
US

IV. Provider business mailing address

577 PINE VALLEY DR SUITE 200
POWDR SPRING GA
30127
US

V. Phone/Fax

Practice location:
  • Phone: 678-523-8082
  • Fax: 678-567-5246
Mailing address:
  • Phone: 678-523-8082
  • Fax: 675-567-5246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number110-R-0225
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number110R0225
License Number StateGA

VIII. Authorized Official

Name: MRS. BETTY KELLY LEE
Title or Position: DIRECTOR/OWENER
Credential: ETC
Phone: 678-523-8082