MEDICARE: PALMGROOVE ENTERPRISES 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	385H00000X	Respite Care

General Provider Information

NPI Number	:	1174931299
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALMGROOVE ENTERPRISES LLC

Provider Business Mailing Address
First Line	:	4174 FORTUNE PT
Second Line	:
City	:	COLLEGE PARK
State	:	GA
Zip	:	30349-1387
Country	:	US
Telephone Number	:	404-409-8365
Fax Number	:

Provider Business Practice Location Address
First Line	:	4174 FORTUNE PT
Second Line	:
City	:	COLLEGE PARK
State	:	GA
Zip	:	30349-1387
Country	:	US
Telephone Number	:	404-409-8365
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KIKELOMO LABIRAN
Credential	:
Telephone Number	:	404-409-8365

Provider Enumeration Date	:	08/01/2014
Last Update Date	:	08/01/2014

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