Healthcare Provider Details

I. General information

NPI: 1306468228
Provider Name (Legal Business Name): MASALON PERSONAL CARE HOME INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3952 ROCKBRIDGE RD
STONE MOUNTAIN GA
30083-4170
US

IV. Provider business mailing address

3952 ROCKBRIDGE RD
STONE MOUNTAIN GA
30083-4170
US

V. Phone/Fax

Practice location:
  • Phone: 917-826-4317
  • Fax:
Mailing address:
  • Phone: 917-826-4317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name: MAKESA MAMIE FOFANA
Title or Position: OWNER
Credential:
Phone: 917-826-4317