=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821338518
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FARETH HEALTHCARE SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2013
-----------------------------------------------------
Last Update Date | 03/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3650 LONG LAKE DR
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-7652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-485-3166
-----------------------------------------------------
Fax | 770-485-3240
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1071
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30133-1071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-485-3166
-----------------------------------------------------
Fax | 770-485-3240
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | TEMILADE OYEKUNLE
-----------------------------------------------------
Credential | LPN
-----------------------------------------------------
Telephone | 770-485-3166
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 048-R-0964
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------