Provider Demographics
NPI:1720578792
Name:JOHN LILLY GROVE HOME CARE LLC
Entity Type:Organization
Organization Name:JOHN LILLY GROVE HOME CARE LLC
Other - Org Name:JLG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-438-6125
Mailing Address - Street 1:206 KINGS CT
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-1010
Mailing Address - Country:US
Mailing Address - Phone:678-438-6125
Mailing Address - Fax:
Practice Address - Street 1:206 KINGS CT
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1010
Practice Address - Country:US
Practice Address - Phone:678-438-6125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care