Provider Demographics
NPI:1447662432
Name:CONCOH HEALTH CARE
Entity type:Organization
Organization Name:CONCOH HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NNEKA
Authorized Official - Middle Name:PAT
Authorized Official - Last Name:ETO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-875-2759
Mailing Address - Street 1:5883 HERITAGE LN
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-1848
Mailing Address - Country:US
Mailing Address - Phone:770-875-2759
Mailing Address - Fax:
Practice Address - Street 1:5883 HERITAGE LN
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-1848
Practice Address - Country:US
Practice Address - Phone:770-875-2759
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-23
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044-R-0676253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003131517AMedicaid