Healthcare Provider Details

I. General information

NPI: 1700462199
Provider Name (Legal Business Name): KENNY'S PERSONAL CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4043 BIG VALLEY TRL
STONE MOUNTAIN GA
30083-5711
US

IV. Provider business mailing address

4043 BIG VALLEY TRL
STONE MOUNTAIN GA
30083-5711
US

V. Phone/Fax

Practice location:
  • Phone: 770-676-0766
  • Fax: 770-676-0766
Mailing address:
  • Phone: 770-676-0766
  • Fax: 770-676-0766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: KENYON LINDSEY
Title or Position: CEO
Credential: CEO, COUNSELOR
Phone: 770-899-2849