Healthcare Provider Details

I. General information

NPI: 1093641896
Provider Name (Legal Business Name): MS. MATHILDA PREVOST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1741 HIGHWAY 138 SW
RIVERDALE GA
30296-1921
US

IV. Provider business mailing address

1741 HIGHWAY 138 SW
RIVERDALE GA
30296-1921
US

V. Phone/Fax

Practice location:
  • Phone: 770-996-5552
  • Fax:
Mailing address:
  • Phone: 770-996-5552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number031012331
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: