MEDICARE: PINK HEARTS HOME CARE SERVICES, 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	251E00000X	Home Health Agency	110-R-2029	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	T180003	OTHER	GA	PRIVATE HOME CARE PROVIDER

General Provider Information

NPI Number	:	1508347246
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINK HEARTS HOME CARE SERVICES, LLC

Provider Business Mailing Address
First Line	:	214 N BECKMAN CT
Second Line	:
City	:	DALLAS
State	:	GA
Zip	:	30132-0417
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	214 N BECKMAN CT
Second Line	:
City	:	DALLAS
State	:	GA
Zip	:	30132-0417
Country	:	US
Telephone Number	:	404-825-0770
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LATOYA LASHELLE SHEPHERD
Credential	:
Telephone Number	:	404-825-0770

Provider Enumeration Date	:	08/21/2018
Last Update Date	:	08/21/2018

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