Healthcare Provider Details

I. General information

NPI: 1972872661
Provider Name (Legal Business Name): COMPREHENSIVE VINE HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2011
Last Update Date: 05/12/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1978 SCARBROUGH DR
STONE MOUNTAIN GA
30088-4422
US

IV. Provider business mailing address

1978 SCARBROUGH DR
STONE MOUNTAIN GA
30088-4422
US

V. Phone/Fax

Practice location:
  • Phone: 404-796-6511
  • Fax: 678-550-9140
Mailing address:
  • Phone: 404-796-6511
  • Fax: 678-550-9140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberRN10908
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberRN109088
License Number StateGA

VIII. Authorized Official

Name: MS. QUINTINA L MACAULEY
Title or Position: OWNER
Credential: NP
Phone: 404-796-6511