MEDICARE: CARING HANDS ASSISTED LIVING, 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	031012331	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	911309871	OTHER	GA	CCSP PROVIDER

General Provider Information

NPI Number	:	1316217045
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARING HANDS ASSISTED LIVING, LLC.

Provider Business Mailing Address
First Line	:	1741 HIGHWAY 138 SW
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30296-1921
Country	:	US
Telephone Number	:	770-996-5552
Fax Number	:	770-996-5552

Provider Business Practice Location Address
First Line	:	1741 HIGHWAY 138 SW
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30296-1921
Country	:	US
Telephone Number	:	770-996-5552
Fax Number	:	770-996-5552

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. MATHILDA PREVOST
Credential	:
Telephone Number	:	678-886-6877

Provider Enumeration Date	:	01/11/2012
Last Update Date	:	01/11/2012

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