MEDICARE: PRIVATE HOME ASSISTANCE OF GEORGIA, INC.

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	033-R-0085	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689743833
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIVATE HOME ASSISTANCE OF GEORGIA, INC.

Provider Business Mailing Address
First Line	:	707 WHITLOCK AVE SW
Second Line	:	SUITE F-3
City	:	MARIETTA
State	:	GA
Zip	:	30064-3000
Country	:	US
Telephone Number	:	678-355-6000
Fax Number	:	678-355-6077

Provider Business Practice Location Address
First Line	:	707 WHITLOCK AVE SW
Second Line	:	SUITE F-3
City	:	MARIETTA
State	:	GA
Zip	:	30064-3000
Country	:	US
Telephone Number	:	678-355-6000
Fax Number	:	678-355-6077

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. RANDALL BROWN
Credential	:	NHA
Telephone Number	:	678-355-6000

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	04/23/2013

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