Provider Demographics
NPI:1083996292
Name:TERRELL'S PERSONAL CARE HOME, INC
Entity Type:Organization
Organization Name:TERRELL'S PERSONAL CARE HOME, INC
Other - Org Name:T AND A'S PERSONAL CARE HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:TERRELL-MOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-338-5091
Mailing Address - Street 1:126 BARRINGTON DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30605-3580
Mailing Address - Country:US
Mailing Address - Phone:706-338-5091
Mailing Address - Fax:866-615-7091
Practice Address - Street 1:5100 ATLANTA HWY
Practice Address - Street 2:5150 ATLANTA HIGHWAY
Practice Address - City:BOGART
Practice Address - State:GA
Practice Address - Zip Code:30622-2109
Practice Address - Country:US
Practice Address - Phone:706-338-5091
Practice Address - Fax:866-615-7091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA233656728AMedicaid
GA404716841BMedicaid