Healthcare Provider Details

I. General information

NPI: 1073847703
Provider Name (Legal Business Name): MILDRED'S HOMEPLACE III
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 09/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 A & B SHORELINE DRIVE
THOMASVILLE GA
31792-4608
US

IV. Provider business mailing address

612 EAST CLAY STREET
THOMASVILLE GA
31792-4608
US

V. Phone/Fax

Practice location:
  • Phone: 229-551-0695
  • Fax: 229-551-0694
Mailing address:
  • Phone: 229-551-0695
  • Fax: 229-551-0694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateGA

VIII. Authorized Official

Name: MRS. NANCY LEE MITCHELL
Title or Position: ADMINISTRATOR
Credential:
Phone: 229-228-1985