=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619851912
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLLIE MAES HOME CARE AGENCY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2025
-----------------------------------------------------
Last Update Date | 08/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 324 CORDER RD STE 800
-----------------------------------------------------
City | WARNER ROBINS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31088-3658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-331-5027
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 CREEK BLUFF TRL
-----------------------------------------------------
City | WARNER ROBINS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31093-7639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-331-5027
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER/MANAGER
-----------------------------------------------------
Name | TONYA FULMORE CANNON
-----------------------------------------------------
Credential | DIRECTOR
-----------------------------------------------------
Telephone | 229-938-8181
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------