=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184335929
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOME HEALTH OF ATLANTA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2022
-----------------------------------------------------
Last Update Date | 12/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3640 S FULTON AVE UNIT 1207
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30354-1762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-617-8293
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6691 CHURCH ST UNIT 962457
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30296-4098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ODELL ANDERSON JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-617-8293
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------