MEDICARE: A&C PRIVATE HOME 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	253Z00000X	In Home Supportive Care Agency	033-R-1499	GA

General Provider Information

NPI Number	:	1598214181
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A&C PRIVATE HOME CARE, LLC

Provider Business Mailing Address
First Line	:	4855 IVY RIDGE DR SE
Second Line	:	UNIT 405
City	:	ATLANTA
State	:	GA
Zip	:	30339-1367
Country	:	US
Telephone Number	:	770-776-6637
Fax Number	:

Provider Business Practice Location Address
First Line	:	4855 IVY RIDGE DR SE
Second Line	:	UNIT 405
City	:	ATLANTA
State	:	GA
Zip	:	30339-1367
Country	:	US
Telephone Number	:	770-776-6637
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	ANGELA C AGWUNOB
Credential	:
Telephone Number	:	770-776-6637

Provider Enumeration Date	:	09/24/2016
Last Update Date	:	09/24/2016

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