Provider Demographics
NPI:1295054278
Name:AGELESS PRIVATE HOME HEALTHCARE
Entity type:Organization
Organization Name:AGELESS PRIVATE HOME HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PEAN
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:404-553-6671
Mailing Address - Street 1:3188 KRISAM CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-7907
Mailing Address - Country:US
Mailing Address - Phone:404-553-6671
Mailing Address - Fax:
Practice Address - Street 1:3188 KRISAM CREEK DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-7907
Practice Address - Country:US
Practice Address - Phone:404-553-6671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-30
Last Update Date:2010-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067-R-0498251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health