Provider Demographics
NPI:1205418365
Name:MILE STONE PERSONAL CARE HOME
Entity Type:Organization
Organization Name:MILE STONE PERSONAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-319-3158
Mailing Address - Street 1:206 ANDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-4144
Mailing Address - Country:US
Mailing Address - Phone:478-319-3158
Mailing Address - Fax:
Practice Address - Street 1:206 ANDERSON AVE
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-4144
Practice Address - Country:US
Practice Address - Phone:478-319-3158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care