Provider Demographics
NPI:1205482098
Name:PEACHTREE HOME CARE
Entity type:Organization
Organization Name:PEACHTREE HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:870-945-5038
Mailing Address - Street 1:1220 MECASLIN ST NW APT 2432
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-5659
Mailing Address - Country:US
Mailing Address - Phone:870-945-5038
Mailing Address - Fax:
Practice Address - Street 1:1220 MECASLIN ST NW APT 2432
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-5659
Practice Address - Country:US
Practice Address - Phone:870-945-5038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care