MEDICARE: OCEANS GATE CARE 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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1285175612
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCEANS GATE CARE LLC

Provider Business Mailing Address
First Line	:	PO BOX 54632
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30308-0632
Country	:	US
Telephone Number	:	404-220-9263
Fax Number	:

Provider Business Practice Location Address
First Line	:	1075 PEACHTREE ST NE
Second Line	:	SUITE 3650
City	:	ATLANTA
State	:	GA
Zip	:	30309-3912
Country	:	US
Telephone Number	:	404-220-9263
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DEVON JOHNSON
Credential	:
Telephone Number	:	404-220-9263

Provider Enumeration Date	:	03/18/2017
Last Update Date	:	03/18/2017

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