Provider Demographics
NPI:1750753133
Name:CARABALLO, JORGE
Entity type:Individual
Prefix:MR
First Name:JORGE
Middle Name:
Last Name:CARABALLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 867
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-6963
Mailing Address - Country:US
Mailing Address - Phone:678-997-4048
Mailing Address - Fax:
Practice Address - Street 1:5672 HARBORMIST DR
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-6963
Practice Address - Country:US
Practice Address - Phone:678-997-4048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOCC014925251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health