Healthcare Provider Details

I. General information

NPI: 1568228963
Provider Name (Legal Business Name): 1111 HOME CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2024
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 WOODWAY PARK DR
SANDY SPRINGS GA
30350-4543
US

IV. Provider business mailing address

118 WOODWAY PARK DR
SANDY SPRINGS GA
30350-4543
US

V. Phone/Fax

Practice location:
  • Phone: 678-492-8661
  • Fax:
Mailing address:
  • Phone: 678-492-8661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES EDWARD JONES JR.
Title or Position: OWNER
Credential:
Phone: 678-492-8661