Provider Demographics
NPI:1609690312
Name:123 GA HOME HEATHCARE LLLP
Entity type:Organization
Organization Name:123 GA HOME HEATHCARE LLLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:WHISBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-554-6864
Mailing Address - Street 1:767 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-2232
Mailing Address - Country:US
Mailing Address - Phone:678-846-9557
Mailing Address - Fax:
Practice Address - Street 1:767 NORTH AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2232
Practice Address - Country:US
Practice Address - Phone:678-846-9557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-09
Last Update Date:2024-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)