Provider Demographics
NPI:1467769398
Name:YILLA PERSONAL CARE HOME, INC
Entity Type:Organization
Organization Name:YILLA PERSONAL CARE HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RACQUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:YILLA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:631-848-3740
Mailing Address - Street 1:6226 WINDY RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-6625
Mailing Address - Country:US
Mailing Address - Phone:631-848-3740
Mailing Address - Fax:770-783-6604
Practice Address - Street 1:6226 WINDY RIDGE TRL
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-6625
Practice Address - Country:US
Practice Address - Phone:631-848-3740
Practice Address - Fax:770-783-6604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2012-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044-01-850-2251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA776635011FMedicaid
GA776635011AMedicaid
GA776635011IMedicaid
GA776635011GMedicaid
GA776635011HMedicaid
GA776635011DMedicaid
GA776635011CMedicaid
GA609202851AMedicaid
GA776635011EMedicaid
GA776635011BMedicaid