=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376321430
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 4ANGELS OF BYROMVILLE HEALTHCARE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2023
-----------------------------------------------------
Last Update Date | 11/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 712 PATTERSON ST
-----------------------------------------------------
City | BYROMVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31007-3760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-349-4507
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 712 PATTERSON ST
-----------------------------------------------------
City | BYROMVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31007-3760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-286-7010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | SLEGNA HEALTHCARE CONSULTANT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 470-349-4507
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------