Provider Demographics
NPI:1760924278
Name:DIVERSIFIED PERSONAL HOME CARE
Entity Type:Organization
Organization Name:DIVERSIFIED PERSONAL HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ADESOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:OSILAJA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-993-1270
Mailing Address - Street 1:145 MCINTOSH PLACE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 MCINTOSH PLACE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7318
Practice Address - Country:US
Practice Address - Phone:404-993-1270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-15
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
GA056-R-1338311500000X, 385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA14028509OtherHOME HEALTH CARE