=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821455759
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOME AWAY FROM HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2016
-----------------------------------------------------
Last Update Date | 01/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5031 GLORE RD SW
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126-5509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-289-3682
-----------------------------------------------------
Fax | 678-321-1464
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5031 GLORE RD SW
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126-5509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-289-3682
-----------------------------------------------------
Fax | 678-321-1464
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | VICKIE BURROW-JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-289-3682
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------