Provider Demographics
NPI:1760816813
Name:OHANA GROUP, LLC
Entity Type:Organization
Organization Name:OHANA GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-825-3380
Mailing Address - Street 1:4124 STEVE REYNOLDS BLVD
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-3059
Mailing Address - Country:US
Mailing Address - Phone:678-924-0037
Mailing Address - Fax:678-924-0038
Practice Address - Street 1:4124 STEVE REYNOLDS BLVD
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-3059
Practice Address - Country:US
Practice Address - Phone:678-924-0037
Practice Address - Fax:678-924-0038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067-R-0870253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003130484AMedicaid