=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487295044
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVING TESTIMONY HOMECARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2019
-----------------------------------------------------
Last Update Date | 09/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10833 SOUTHWOOD DRIVE
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-454-0843
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10833 SOUTHWOOD DRIVE
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-454-0843
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RN
-----------------------------------------------------
Name | JULIET IDEMUDIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-454-0843
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------