=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801180484
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLCARE OF NORTH GEORGIA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2011
-----------------------------------------------------
Last Update Date | 06/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5859 LOVE ST
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30168-4030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-920-8546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 348
-----------------------------------------------------
City | CLARKDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30111-0348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-920-8546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. ROSELINE AKAROLO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-920-8546
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------