Provider Demographics
NPI:1396409918
Name:STELLA GROVE HEALTH LLC
Entity Type:Organization
Organization Name:STELLA GROVE HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR - OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:DEVON
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-759-6625
Mailing Address - Street 1:321 THOROUGHBRED LN
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-4107
Mailing Address - Country:US
Mailing Address - Phone:404-759-6625
Mailing Address - Fax:
Practice Address - Street 1:321 THOROUGHBRED LN
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-4107
Practice Address - Country:US
Practice Address - Phone:404-759-6625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-29
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home