Provider Demographics
NPI:1235638412
Name:MALIBU COMPANION SERVICES, LLC
Entity Type:Organization
Organization Name:MALIBU COMPANION SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:
Authorized Official - First Name:MARTHE
Authorized Official - Middle Name:
Authorized Official - Last Name:PIERRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-873-6303
Mailing Address - Street 1:8106 WOODLAND CT SE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-3958
Mailing Address - Country:US
Mailing Address - Phone:770-873-6303
Mailing Address - Fax:678-625-2662
Practice Address - Street 1:7407 COCOANUT DR
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-6421
Practice Address - Country:US
Practice Address - Phone:770-873-6303
Practice Address - Fax:678-625-2662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
1234OtherAGENT
FL1234Medicaid
GA330382076AMedicaid