Provider Demographics
NPI:1013548312
Name:BRADFORDVILLE SANTEE PROVIDENCE COMMUNITY HOME CARE, LLC
Entity Type:Organization
Organization Name:BRADFORDVILLE SANTEE PROVIDENCE COMMUNITY HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:404-793-2025
Mailing Address - Street 1:307 SAWYER MEADOW WAY
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-4176
Mailing Address - Country:US
Mailing Address - Phone:404-793-2025
Mailing Address - Fax:404-793-2020
Practice Address - Street 1:307 SAWYER MEADOW WAY
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-4176
Practice Address - Country:US
Practice Address - Phone:404-793-2025
Practice Address - Fax:404-793-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care