Healthcare Provider Details

I. General information

NPI: 1801056791
Provider Name (Legal Business Name): PETLIN DIVERSIFIED SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 LOST LAKES WAY
POWDER SPRINGS GA
30127-6018
US

IV. Provider business mailing address

2817 LOST LAKES WAY
POWDER SPRINGS GA
30127-6018
US

V. Phone/Fax

Practice location:
  • Phone: 770-595-8934
  • Fax:
Mailing address:
  • Phone: 770-595-8934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberRN155427NP
License Number StateGA

VIII. Authorized Official

Name: MRS. LINDA ANGELA MBAH
Title or Position: CEO
Credential: NP
Phone: 770-595-8934