Provider Demographics
NPI:1750075529
Name:MARYLILHOMECAREANDGIRLSCLUB
Entity type:Organization
Organization Name:MARYLILHOMECAREANDGIRLSCLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:MARRIETTA
Authorized Official - Last Name:JACKSON-JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-922-9489
Mailing Address - Street 1:2932 BREVARD AVE
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36109-2135
Mailing Address - Country:US
Mailing Address - Phone:973-220-2875
Mailing Address - Fax:
Practice Address - Street 1:1041 PERRY HILL RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36109-4500
Practice Address - Country:US
Practice Address - Phone:334-922-9489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty