=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962055640
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILEMON HEALTHCARE SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2019
-----------------------------------------------------
Last Update Date | 07/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 925 MAIN ST STE 300-116
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30083-3098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-932-8056
-----------------------------------------------------
Fax | 678-797-7020
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 622 PENNYLAKE LANE
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30087-5768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-465-9386
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MRS. RUTHIE A THOMPSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-465-9386
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------