Provider Demographics
NPI:1841739984
Name:UNDER THE SHADOWS PRIVATE HOME CARE
Entity Type:Organization
Organization Name:UNDER THE SHADOWS PRIVATE HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-978-8282
Mailing Address - Street 1:208 CURTIS ST
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:GA
Mailing Address - Zip Code:30467-2432
Mailing Address - Country:US
Mailing Address - Phone:912-564-5865
Mailing Address - Fax:
Practice Address - Street 1:208 CURTIS STREET
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:GA
Practice Address - Zip Code:30467
Practice Address - Country:US
Practice Address - Phone:912-978-8282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047470140302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization