Provider Demographics
NPI:1730313222
Name:SAFEWAY HEALTHCARE, INC.
Entity Type:Organization
Organization Name:SAFEWAY HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BENSON
Authorized Official - Middle Name:NOSA
Authorized Official - Last Name:AGBONAVBARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-255-9500
Mailing Address - Street 1:2386 CLOWER STREET, BUILDING C, SUITE 209
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6108
Mailing Address - Country:US
Mailing Address - Phone:770-255-9500
Mailing Address - Fax:770-733-1329
Practice Address - Street 1:3846 WOOD HOLLOW WAY
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-6080
Practice Address - Country:US
Practice Address - Phone:770-255-9500
Practice Address - Fax:770-733-1329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-12
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA44-R-0203253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care