MEDICARE: EBONY POLK

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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1588106397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY POLK

Provider Business Mailing Address
First Line	:	63 ACORN DR
Second Line	:
City	:	DALLAS
State	:	GA
Zip	:	30157-3043
Country	:	US
Telephone Number	:	678-515-1844
Fax Number	:	678-515-1843

Provider Business Practice Location Address
First Line	:	63 ACORN DR
Second Line	:
City	:	DALLAS
State	:	GA
Zip	:	30157-3043
Country	:	US
Telephone Number	:	678-515-1844
Fax Number	:	678-515-1843

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2016
Last Update Date	:	11/09/2016

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Directions to “ EBONY POLK ” Practice Location

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