Provider Demographics
NPI:1053669986
Name:LE'GLEN PERSONAL CARE HOME
Entity Type:Organization
Organization Name:LE'GLEN PERSONAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:GLYNDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ETCHISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-963-1599
Mailing Address - Street 1:2490 BOULDER SPRINGS PT
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-1762
Mailing Address - Country:US
Mailing Address - Phone:404-963-1599
Mailing Address - Fax:
Practice Address - Street 1:2490 BOULDER SPRINGS PT
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-1762
Practice Address - Country:US
Practice Address - Phone:404-963-1599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCH008098251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health