=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447670518
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | APEX FAMILY HEALTHCARE SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2014
-----------------------------------------------------
Last Update Date | 04/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 159 BURKE ST STE 201
-----------------------------------------------------
City | STOCKBRIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30281-3430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-948-7476
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 159 BURKE ST STE 201
-----------------------------------------------------
City | STOCKBRIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30281-3430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-948-7476
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | MRS. DEMETRIA ANN BOLAR
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 678-948-7476
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | LPC007280
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | LPC007280
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------