Provider Demographics
NPI:1447816608
Name:GKHAIRSTON II LLC
Entity type:Organization
Organization Name:GKHAIRSTON II LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:HAIRSTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH,MBA
Authorized Official - Phone:470-625-2205
Mailing Address - Street 1:320 LANIER AVE W STE 200
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7443
Mailing Address - Country:US
Mailing Address - Phone:470-625-2193
Mailing Address - Fax:470-300-7662
Practice Address - Street 1:320 LANIER AVE W STE 200
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7443
Practice Address - Country:US
Practice Address - Phone:470-625-2205
Practice Address - Fax:470-300-7662
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHCP010398
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-14
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPHCP010398OtherSTATE OF GA
GAPHCP010398OtherIN HOME CARE SERVICES