Provider Demographics
NPI:1073847703
Name:MILDRED'S HOMEPLACE III
Entity Type:Organization
Organization Name:MILDRED'S HOMEPLACE III
Other - Org Name:THE HOMEPLACE SHELTER INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-228-1985
Mailing Address - Street 1:612 EAST CLAY STREET
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-4608
Mailing Address - Country:US
Mailing Address - Phone:229-551-0695
Mailing Address - Fax:229-551-0694
Practice Address - Street 1:357 A & B SHORELINE DRIVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-4608
Practice Address - Country:US
Practice Address - Phone:229-551-0695
Practice Address - Fax:229-551-0694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251G00000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA136-01-096-1OtherPERSONALCARE HOME