Provider Demographics
NPI:1679091458
Name:SPECIALIZED HEALTHCARE SERVICES INC
Entity Type:Organization
Organization Name:SPECIALIZED HEALTHCARE SERVICES INC
Other - Org Name:SPECIALIZED HEALTHCARE SERVICES LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:CONTRACTS ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOHNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-604-5691
Mailing Address - Street 1:2920 TOBACCO RD STE A
Mailing Address - Street 2:
Mailing Address - City:HEPHZIBAH
Mailing Address - State:GA
Mailing Address - Zip Code:30815-9012
Mailing Address - Country:US
Mailing Address - Phone:770-365-0578
Mailing Address - Fax:
Practice Address - Street 1:2920 TOBACCO ROAD, SUIT A
Practice Address - Street 2:
Practice Address - City:HEPHZIBAH
Practice Address - State:GA
Practice Address - Zip Code:30815
Practice Address - Country:US
Practice Address - Phone:770-365-0578
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033-R-1448253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care