Provider Demographics
NPI:1043619141
Name:PEACHTREE HOME HEALTH, LLC
Entity Type:Organization
Organization Name:PEACHTREE HOME HEALTH, LLC
Other - Org Name:BRIDGEWAY HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:RASMUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-427-2700
Mailing Address - Street 1:1395 S MARIETTA PKWY SE BLDG 400 SUITE 102
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-7852
Mailing Address - Country:US
Mailing Address - Phone:678-932-6302
Mailing Address - Fax:678-402-5246
Practice Address - Street 1:2135 EASTVIEW PKWY STE 800
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-5772
Practice Address - Country:US
Practice Address - Phone:678-806-5336
Practice Address - Fax:678-806-5350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA122 - 195251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA117111Medicare Oscar/Certification