Provider Demographics
NPI:1952531956
Name:MIMS CARE HOME
Entity Type:Organization
Organization Name:MIMS CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:
Authorized Official - First Name:OLUBISI
Authorized Official - Middle Name:EMMANUEL
Authorized Official - Last Name:OLUYEMI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:404-569-1041
Mailing Address - Street 1:2103 JOCKEY HOLLOW DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-3169
Mailing Address - Country:US
Mailing Address - Phone:404-569-1041
Mailing Address - Fax:770-422-5929
Practice Address - Street 1:1589 MIMS ST SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30314-2255
Practice Address - Country:US
Practice Address - Phone:404-569-1041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-24
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060-01-360-9261QA0600X, 261QM0850X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health