=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235613159
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ESTHER ANGELS HOMECARE AND ASSISTED LIVING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2018
-----------------------------------------------------
Last Update Date | 09/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 LLOYD AVE STE B
-----------------------------------------------------
City | TYRONE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30290-2157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-519-3088
-----------------------------------------------------
Fax | 800-273-7168
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 LLOYD AVE STE B
-----------------------------------------------------
City | TYRONE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30290-2157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-519-3088
-----------------------------------------------------
Fax | 800-273-7168
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | OLUSEGUN AJIBADE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-519-3088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------