Provider Demographics
NPI:1790196772
Name:BURST OF JOY PERSONAL CARE
Entity Type:Organization
Organization Name:BURST OF JOY PERSONAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VENTRISHA
Authorized Official - Middle Name:LINETT
Authorized Official - Last Name:MOLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-378-0693
Mailing Address - Street 1:P.O. BOX 144
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39828-3288
Mailing Address - Country:US
Mailing Address - Phone:229-378-0693
Mailing Address - Fax:229-397-0819
Practice Address - Street 1:396 7TH AVE SE
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828-3070
Practice Address - Country:US
Practice Address - Phone:229-397-0819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA065-01-023-1261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health