Provider Demographics
NPI:1356498737
Name:MARMALADE HEALTHCARE LLC
Entity type:Organization
Organization Name:MARMALADE HEALTHCARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:PETRY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:770-464-5858
Mailing Address - Street 1:215 AZALEA CT
Mailing Address - Street 2:
Mailing Address - City:SOCIAL CIRCLE
Mailing Address - State:GA
Mailing Address - Zip Code:30025-5037
Mailing Address - Country:US
Mailing Address - Phone:770-464-5858
Mailing Address - Fax:770-464-5870
Practice Address - Street 1:215 AZALEA CT
Practice Address - Street 2:
Practice Address - City:SOCIAL CIRCLE
Practice Address - State:GA
Practice Address - Zip Code:30025-5037
Practice Address - Country:US
Practice Address - Phone:770-464-5858
Practice Address - Fax:770-464-5870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA107151H251G00000X, 315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251G00000XAgenciesHospice Care, Community Based
Not Answered315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00598925Medicaid
GA111530Medicare ID - Type Unspecified