Healthcare Provider Details

I. General information

NPI: 1114228665
Provider Name (Legal Business Name): GLORIA HOME CARE AGENCY AND SUPPORT STAFFING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2010
Last Update Date: 04/22/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 CONNELL RD
VALDOSTA GA
31602-1481
US

IV. Provider business mailing address

428 CONNELL RD
VALDOSTA GA
31602-1481
US

V. Phone/Fax

Practice location:
  • Phone: 229-249-7717
  • Fax: 229-231-3030
Mailing address:
  • Phone: 229-249-7717
  • Fax: 229-231-3030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number092-R-0566
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number092-R-0566
License Number StateGA

VIII. Authorized Official

Name: GLORIA JEAN ANDERSON
Title or Position: CEO
Credential:
Phone: 229-249-7717