MEDICARE: SIMPLICITYS PERSONAL CARE HOME LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1053934802
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIMPLICITYS PERSONAL CARE HOME LLC

Provider Business Mailing Address
First Line	:	PO BOX 11
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30301-0011
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6741 CHURCH ST STE 2
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30274-2249
Country	:	US
Telephone Number	:	678-886-7320
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	VALERIE RACHEL
Credential	:
Telephone Number	:	678-886-7320

Provider Enumeration Date	:	05/27/2020
Last Update Date	:	05/27/2020

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