=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841624095
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEACEFUL LOVE & CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2013
-----------------------------------------------------
Last Update Date | 08/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 815 PINE ROC DR
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30083-3521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-374-0862
-----------------------------------------------------
Fax | 470-299-3170
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 815 PINE ROC DR
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30083-3521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-374-0862
-----------------------------------------------------
Fax | 470-299-3170
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HOME HEALTH AIDE
-----------------------------------------------------
Name | JOCELYN LYN HAMMPMD
-----------------------------------------------------
Credential | HHA
-----------------------------------------------------
Telephone | 770-374-0862
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | CN0019212211
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------