Provider Demographics
NPI:1790793628
Name:MEMORIAL CAREONE HOME HEALTH SERVICES, INC
Entity Type:Organization
Organization Name:MEMORIAL CAREONE HOME HEALTH SERVICES, INC
Other - Org Name:CAREONE HOME HEALTH SERVICES-VIDALIA AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILDES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:912-350-6559
Mailing Address - Street 1:PO BOX 931861
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31198-1861
Mailing Address - Country:US
Mailing Address - Phone:912-350-6405
Mailing Address - Fax:912-350-6413
Practice Address - Street 1:201 MAPLE DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8906
Practice Address - Country:US
Practice Address - Phone:912-537-9004
Practice Address - Fax:912-537-0235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA138-112251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
5817100600 006OtherBCBS
GA00336894AMedicaid
117423OtherJCAHO
51000682 001OtherBCBS
5817100600 006OtherBCBS