MEDICARE: VINE CARE 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1770341372
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VINE CARE HOME CARE LLC

Provider Business Mailing Address
First Line	:	2682 JACANAR LN SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-8008
Country	:	US
Telephone Number	:	678-457-7916
Fax Number	:

Provider Business Practice Location Address
First Line	:	2682 JACANAR LN SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-8008
Country	:	US
Telephone Number	:	678-457-7916
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TRENEVA OKODUWA
Credential	:
Telephone Number	:	770-609-9140

Provider Enumeration Date	:	03/08/2024
Last Update Date	:	03/08/2024

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