=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609235670
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOLLY'S PERSONAL CARE HME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2016
-----------------------------------------------------
Last Update Date | 02/24/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 COTTON CREEK LN
-----------------------------------------------------
City | WINDER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30680-8304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-559-9009
-----------------------------------------------------
Fax | 678-261-5928
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38 S BROAD ST STE 100
-----------------------------------------------------
City | WINDER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30680-8000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-559-9009
-----------------------------------------------------
Fax | 678-261-5928
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL MANAGER
-----------------------------------------------------
Name | MS. CYNTHIA VINCENT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-215-6241
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------