Provider Demographics
NPI:1225333925
Name:NAG ENTERPRISE GROUP
Entity Type:Organization
Organization Name:NAG ENTERPRISE GROUP
Other - Org Name:GRANNY NANNIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NGIRI
Authorized Official - Middle Name:DENESE
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-530-0040
Mailing Address - Street 1:3401 NORMAN BERRY DR
Mailing Address - Street 2:SUITE 276
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-5121
Mailing Address - Country:US
Mailing Address - Phone:404-530-0040
Mailing Address - Fax:404-530-0045
Practice Address - Street 1:3401 NORMAN BERRY DR
Practice Address - Street 2:SUITE 276
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-5121
Practice Address - Country:US
Practice Address - Phone:404-530-0040
Practice Address - Fax:404-530-0045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA610166556AMedicaid