=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508546961
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POSITIVE CARE PERSONAL CARE HOME, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2023
-----------------------------------------------------
Last Update Date | 07/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 212 WILLIS DR
-----------------------------------------------------
City | STOCKBRIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30281-7272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-507-0123
-----------------------------------------------------
Fax | 770-507-7021
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 WILLIS DR
-----------------------------------------------------
City | STOCKBRIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30281-7272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-507-0123
-----------------------------------------------------
Fax | 770-507-7021
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MARY L WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-467-1087
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------