Provider Demographics
NPI:1689743833
Name:PRIVATE HOME ASSISTANCE OF GEORGIA, INC.
Entity Type:Organization
Organization Name:PRIVATE HOME ASSISTANCE OF GEORGIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:678-355-6000
Mailing Address - Street 1:707 WHITLOCK AVE SW
Mailing Address - Street 2:SUITE F-3
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-3000
Mailing Address - Country:US
Mailing Address - Phone:678-355-6000
Mailing Address - Fax:678-355-6077
Practice Address - Street 1:707 WHITLOCK AVE SW
Practice Address - Street 2:SUITE F-3
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-3000
Practice Address - Country:US
Practice Address - Phone:678-355-6000
Practice Address - Fax:678-355-6077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033-R-0085251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA530581025AMedicaid
GA530581025BMedicaid