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General NPI Number Information
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NPI Number | 1932540903
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Entity Type | Organization
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Legal Business Name | TRYST PRIVATE HOMECARE INC
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Dates
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Enumeration Date | 07/08/2013
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Last Update Date | 07/08/2013
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Provider Practice Location Address
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Address Line | 331 BLACK WILLOW CT
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City | LOCUST GROVE
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State | GA
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Zip | 30248-6606
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Country | US
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Telephone | 770-598-7558
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Fax | 678-432-5075
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Provider Business Mailing Address
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Address Line | 331 BLACK WILLOW CT
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City | LOCUST GROVE
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State | GA
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Zip | 30248-6606
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Country | US
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Telephone | 770-598-7558
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Fax | 678-432-5075
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Authorized Official
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Title or Position | CEO
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Name | MODUPE OLUYEMISI SALAMI
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Credential | FNP
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Telephone | 770-598-7558
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number | 075-R-0884
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License Number State | GA
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