Provider Demographics
NPI:1922424886
Name:PRIVATECARENURSINGSERVICELLC
Entity Type:Organization
Organization Name:PRIVATECARENURSINGSERVICELLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTOR
Authorized Official - Prefix:
Authorized Official - First Name:ATHENA
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-846-1793
Mailing Address - Street 1:PO BOX 391812
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-0031
Mailing Address - Country:US
Mailing Address - Phone:386-846-1793
Mailing Address - Fax:
Practice Address - Street 1:3200 SUMMIT PLACE DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-5334
Practice Address - Country:US
Practice Address - Phone:386-846-1793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA066307261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========Medicaid