Provider Demographics
NPI:1851009252
Name:PERSONAL SENIOR HOME CARE, LLC
Entity Type:Organization
Organization Name:PERSONAL SENIOR HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/RN
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:K
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-606-8430
Mailing Address - Street 1:600 HIGHPOINT WAY
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4699
Mailing Address - Country:US
Mailing Address - Phone:404-606-8430
Mailing Address - Fax:
Practice Address - Street 1:981 LUTHER ST SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-6923
Practice Address - Country:US
Practice Address - Phone:404-606-8430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1255703088Medicaid