Provider Demographics
NPI:1235537499
Name:LIFETIME PERSONAL CARE HOME, LNC.
Entity Type:Organization
Organization Name:LIFETIME PERSONAL CARE HOME, LNC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ADEDOYIN
Authorized Official - Middle Name:VICTORIA
Authorized Official - Last Name:AYENI
Authorized Official - Suffix:
Authorized Official - Credentials:ASSOCAITE
Authorized Official - Phone:678-985-0456
Mailing Address - Street 1:40 AUBURN PARK DR
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30011-3643
Mailing Address - Country:US
Mailing Address - Phone:678-985-0456
Mailing Address - Fax:
Practice Address - Street 1:40 AUBURN PARK DRIVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:GA
Practice Address - Zip Code:30011
Practice Address - Country:US
Practice Address - Phone:678-985-0456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-19
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067-R-0355251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health