Provider Demographics
NPI:1003465626
Name:PENISTON PERSONAL CARE HOME,LLC
Entity Type:Organization
Organization Name:PENISTON PERSONAL CARE HOME,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BREEZY
Authorized Official - Middle Name:U
Authorized Official - Last Name:HOUSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-545-3934
Mailing Address - Street 1:4680 SUNDRIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-1997
Mailing Address - Country:US
Mailing Address - Phone:678-545-3934
Mailing Address - Fax:770-892-1051
Practice Address - Street 1:4680 SUNDRIDGE TRL
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-1997
Practice Address - Country:US
Practice Address - Phone:678-545-3934
Practice Address - Fax:770-892-1051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-06
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Multi-Specialty
No163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003217267BMedicaid
GA003217267AMedicaid