Provider Demographics
NPI:1811123615
Name:HOME CARE OF WEST GA LLC
Entity type:Organization
Organization Name:HOME CARE OF WEST GA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BAIRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-705-8717
Mailing Address - Street 1:3088 MERCER UNIVERSITY DRIVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CHAMBLEE
Mailing Address - State:GA
Mailing Address - Zip Code:30341
Mailing Address - Country:US
Mailing Address - Phone:678-705-8717
Mailing Address - Fax:404-935-6110
Practice Address - Street 1:3088 MERCER UNIVERSITY DRIVE
Practice Address - Street 2:SUITE 210
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341
Practice Address - Country:US
Practice Address - Phone:678-705-8717
Practice Address - Fax:404-935-6110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-08
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060R0226253Z00000X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA370024140Medicaid