Provider Demographics
NPI:1033696810
Name:PRESTIGIOUS CARE LLC
Entity Type:Organization
Organization Name:PRESTIGIOUS CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAMEESHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GILMORE
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:631-603-1826
Mailing Address - Street 1:532 BUNCHGRASS ST
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-0369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:532 BUNCHGRASS ST
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-0369
Practice Address - Country:US
Practice Address - Phone:631-603-1826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-24
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherPRIVATE PAY
GA=========Medicaid