=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407986391
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERIM HEALTHCARE OF NORTHEAST GEORGIA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1062 THOMPSON BRIDGE RD SUITE B-7
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30501-1762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-534-0083
-----------------------------------------------------
Fax | 770-534-2443
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1062 THOMPSON BRIDGE RD SUITE B-7
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30501-1762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-534-0083
-----------------------------------------------------
Fax | 770-534-2443
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MS. LACY ANN KENNY
-----------------------------------------------------
Credential | R.N.
-----------------------------------------------------
Telephone | 770-534-0083
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 069-R-0021
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------