Provider Demographics
NPI:1821455759
Name:HOME AWAY FROM HOME
Entity Type:Organization
Organization Name:HOME AWAY FROM HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURROW-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-289-3682
Mailing Address - Street 1:5031 GLORE RD SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-5509
Mailing Address - Country:US
Mailing Address - Phone:770-289-3682
Mailing Address - Fax:678-321-1464
Practice Address - Street 1:5031 GLORE RD SW
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-5509
Practice Address - Country:US
Practice Address - Phone:770-289-3682
Practice Address - Fax:678-321-1464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care