Provider Demographics
NPI:1447569173
Name:AMICUS HOME CARE
Entity Type:Organization
Organization Name:AMICUS HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIZAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-367-4118
Mailing Address - Street 1:4306 GRAYSON PL
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2789
Mailing Address - Country:US
Mailing Address - Phone:678-549-3939
Mailing Address - Fax:404-228-7288
Practice Address - Street 1:954 S MAIN ST NE
Practice Address - Street 2:SUITE 200
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-4551
Practice Address - Country:US
Practice Address - Phone:678-549-3939
Practice Address - Fax:404-228-7288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA122-R-0514251J00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA919016846AMedicaid