Provider Demographics
NPI:1972880896
Name:ALTUS HOSPICE OF GEORGIA LLC
Entity Type:Organization
Organization Name:ALTUS HOSPICE OF GEORGIA LLC
Other - Org Name:HALCYON HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:STELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-233-1307
Mailing Address - Street 1:PO BOX 51266
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-1266
Mailing Address - Country:US
Mailing Address - Phone:337-233-1307
Mailing Address - Fax:337-233-5764
Practice Address - Street 1:5411 NORTHLAND DR
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-2061
Practice Address - Country:US
Practice Address - Phone:770-730-8405
Practice Address - Fax:770-730-8408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-06
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA777588136AMedicaid
GA777588136AMedicaid