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General NPI Number Information
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NPI Number | 1952531956
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Entity Type | Organization
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Legal Business Name | MIMS CARE HOME
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Dates
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Enumeration Date | 07/24/2009
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Last Update Date | 07/24/2009
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Provider Practice Location Address
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Address Line | 1589 MIMS ST SW
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City | ATLANTA
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State | GA
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Zip | 30314-2255
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Country | US
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Telephone | 404-569-1041
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Fax |
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Provider Business Mailing Address
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Address Line | 2103 JOCKEY HOLLOW DR NW
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City | KENNESAW
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State | GA
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Zip | 30152-3169
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Country | US
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Telephone | 404-569-1041
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Fax | 770-422-5929
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Authorized Official
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Title or Position | C.E.O
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Name | OLUBISI EMMANUEL OLUYEMI
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Credential | PH.D
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Telephone | 404-569-1041
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number | 060-01-360-9
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 060-01-360-9
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 060-01-360-9
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License Number State | GA
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