Provider Demographics
NPI:1881955607
Name:EXPRESS HOME CARE GEORGIA
Entity type:Organization
Organization Name:EXPRESS HOME CARE GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-948-8112
Mailing Address - Street 1:231 MAXHAM RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30168-5523
Mailing Address - Country:US
Mailing Address - Phone:770-948-8112
Mailing Address - Fax:770-948-8113
Practice Address - Street 1:231 MAXHAM RD
Practice Address - Street 2:SUITE 100
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30168-5523
Practice Address - Country:US
Practice Address - Phone:770-948-8112
Practice Address - Fax:770-948-8113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FM048R1033253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care