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General NPI Number Information
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NPI Number | 1841622925
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Entity Type | Organization
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Legal Business Name | THE 90 GROUP, LLC
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Dates
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Enumeration Date | 07/31/2013
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Last Update Date | 08/19/2019
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Provider Practice Location Address
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Address Line | 1800 PHOENIX BLVD STE 400
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City | ATLANTA
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State | GA
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Zip | 30349-5560
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Country | US
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Telephone | 770-790-0012
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Fax | 866-205-6289
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Provider Business Mailing Address
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Address Line | 1800 PHOENIX BLVD BLDG 400 SUITE 400 #16
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City | COLLEGE PARK
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State | GA
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Zip | 30349
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Country | US
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Telephone | 770-790-0012
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Fax | 866-205-6289
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Authorized Official
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Title or Position | OWNER
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Name | MS. MICHELE LEE ELLIS-WILLIAMS
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Credential | QDCP
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Telephone | 770-790-0012
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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 | 110-R-1162
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License Number State | GA
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