Provider Demographics
NPI:1043632334
Name:PEACHTREE HOSPICE OF GEORGIA, LLC
Entity Type:Organization
Organization Name:PEACHTREE HOSPICE OF GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-949-0400
Mailing Address - Street 1:135 GEMINI CIR STE 202
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-5842
Mailing Address - Country:US
Mailing Address - Phone:205-949-0400
Mailing Address - Fax:205-949-0405
Practice Address - Street 1:200 BUSINESS CENTER DR STE 204
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9025
Practice Address - Country:US
Practice Address - Phone:678-583-2269
Practice Address - Fax:678-583-2270
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRIDENT HEALTHCARE SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-06
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA111734Medicare Oscar/Certification