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General NPI Number Information
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NPI Number | 1790256931
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Entity Type | Organization
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Legal Business Name | CHANGE OF LIFE COMPANION HOMECARE LLC
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Dates
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Enumeration Date | 12/16/2018
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Last Update Date | 12/16/2018
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Provider Practice Location Address
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Address Line | 401 TOPAZ TRAIL PEACHTREE CITY
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City | FAYETTEVILLE
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State | GA
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Zip | 30269
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Country | US
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Telephone | 404-307-7223
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Fax |
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Provider Business Mailing Address
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Address Line | P.O. BOX 87242
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City | COLLEGE PARK
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State | GA
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Zip | 30337
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Country | US
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Telephone | 404-307-7223
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR DIRECTOR (OWNER)
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Name | MRS. NATASHA D YVETTE DUNN
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Credential |
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Telephone | 404-307-7223
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number |
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License Number State |
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