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General NPI Number Information
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NPI Number | 1922424886
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Entity Type | Organization
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Legal Business Name | PRIVATECARENURSINGSERVICELLC
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Dates
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Enumeration Date | 03/14/2014
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Last Update Date | 03/14/2014
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Provider Practice Location Address
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Address Line | 3200 SUMMIT PLACE DR
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City | LOGANVILLE
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State | GA
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Zip | 30052-5334
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Country | US
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Telephone | 386-846-1793
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 391812
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City | SNELLVILLE
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State | GA
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Zip | 30039-0031
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Country | US
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Telephone | 386-846-1793
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Fax |
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Authorized Official
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Title or Position | ADMINSTOR
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Name | ATHENA TOLIVER
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Credential |
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Telephone | 386-846-1793
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 066307
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License Number State | GA
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