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General NPI Number Information
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NPI Number | 1679958003
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Entity Type | Organization
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Legal Business Name | N/A AT PRESENT TIME, WILL BE WORKING CONTRACTPRIVATEDUTY
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Dates
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Enumeration Date | 07/28/2015
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Last Update Date | 07/28/2015
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Provider Practice Location Address
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Address Line | 401A BOULEVARD 401ABOULEVARD
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City | LAGRANGE
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State | GA
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Zip | 30240-3009
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Country | US
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Telephone | 706-333-9369
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Fax |
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Provider Business Mailing Address
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Address Line | 401A BOULEVARD 401ABOULEVARD
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City | LAGRANGE
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State | GA
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Zip | 30240-3009
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Country | US
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Telephone | 706-333-9369
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Fax |
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Authorized Official
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Title or Position | CNA
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Name | MISS LISA POTTS
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Credential | CERTIFIED NURSING AS
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Telephone | 706-333-9369
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 376K00000X
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Taxonomy Name | Nurse's Aide
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License Number | CN0000047840
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License Number State | AL
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Taxonomy #2
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number | CN0000047840
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License Number State | GA
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