Provider Demographics
NPI:1033894068
Name:PROUD LIFE HOME CARE LLC
Entity Type:Organization
Organization Name:PROUD LIFE HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:M
Authorized Official - Last Name:REESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-818-9606
Mailing Address - Street 1:1700 NORTHSIDE DR
Mailing Address - Street 2:STE A7, UNIT 5861
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318
Mailing Address - Country:US
Mailing Address - Phone:678-883-1407
Mailing Address - Fax:
Practice Address - Street 1:10053 TARA GLYNN DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-6131
Practice Address - Country:US
Practice Address - Phone:678-883-1407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle