Provider Demographics
NPI:1578276887
Name:PREVENTIVE & FITNESS HEALTHCARE AGENCY, LLC
Entity Type:Organization
Organization Name:PREVENTIVE & FITNESS HEALTHCARE AGENCY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WYLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:WORTHEN
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:478-456-9438
Mailing Address - Street 1:1800 N RIDGE DR STE 1
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-2258
Mailing Address - Country:US
Mailing Address - Phone:478-295-2955
Mailing Address - Fax:475-295-3210
Practice Address - Street 1:1800 N RIDGE DR STE 1
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2258
Practice Address - Country:US
Practice Address - Phone:478-295-2955
Practice Address - Fax:475-295-3210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003232271AMedicaid