Healthcare Provider Details

I. General information

NPI: 1073189601
Provider Name (Legal Business Name): PEACH HILL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 S SUSAN CREEK DR
STONE MOUNTAIN GA
30083-4426
US

IV. Provider business mailing address

450 S SUSAN CREEK DR
STONE MOUNTAIN GA
30083-4426
US

V. Phone/Fax

Practice location:
  • Phone: 805-212-0203
  • Fax:
Mailing address:
  • Phone: 805-212-0203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MARIA J QUINONES
Title or Position: GENERAL MANAGER
Credential: LPN/LVN
Phone: 805-212-0203