Provider Demographics
NPI:1518544832
Name:REDWOOD PRIVATE CARE, LLC
Entity Type:Organization
Organization Name:REDWOOD PRIVATE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OWMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOULOUTE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:678-517-4214
Mailing Address - Street 1:3904 N DRUID HILLS RD STE 104
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-3105
Mailing Address - Country:US
Mailing Address - Phone:678-517-4214
Mailing Address - Fax:
Practice Address - Street 1:3715 NORTHSIDE PARKWAY
Practice Address - Street 2:BUILDING 100 - SUITE 500
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327
Practice Address - Country:US
Practice Address - Phone:678-517-4214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-24
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health