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General NPI Number Information
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NPI Number | 1003465626
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Entity Type | Organization
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Legal Business Name | PENISTON PERSONAL CARE HOME,LLC
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Dates
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Enumeration Date | 09/06/2019
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Last Update Date | 05/18/2023
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Provider Practice Location Address
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Address Line | 4680 SUNDRIDGE TRL
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City | FAIRBURN
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State | GA
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Zip | 30213-1997
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Country | US
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Telephone | 678-545-3934
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Fax | 770-892-1051
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Provider Business Mailing Address
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Address Line | 4680 SUNDRIDGE TRL
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City | FAIRBURN
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State | GA
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Zip | 30213-1997
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Country | US
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Telephone | 678-545-3934
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Fax | 770-892-1051
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Authorized Official
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Title or Position | OWNER
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Name | BREEZY U HOUSTON
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Credential |
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Telephone | 678-545-3934
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State | NULL
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Taxonomy #2
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Taxonomy Code | 374U00000X
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Taxonomy Name | Home Health Aide
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License Number |
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License Number State | NULL
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Taxonomy #3
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Taxonomy Code | 163WH0200X
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Taxonomy Name | Home Health Registered Nurse
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License Number |
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License Number State | NULL
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