Provider Demographics
NPI:1871889956
Name:SUNCREST HOME HEALTH-SOUTHSIDE, LLC
Entity type:Organization
Organization Name:SUNCREST HOME HEALTH-SOUTHSIDE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CLAUDIO
Authorized Official - Middle Name:
Authorized Official - Last Name:AZZARITI
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:404-564-7009
Mailing Address - Street 1:PO BOX 6687
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-0687
Mailing Address - Country:US
Mailing Address - Phone:404-688-1350
Mailing Address - Fax:404-688-2962
Practice Address - Street 1:1039 RIDGE AVE SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-1601
Practice Address - Country:US
Practice Address - Phone:770-393-2309
Practice Address - Fax:770-668-0522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-27
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044-293H251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003126784AMedicaid
GA117022Medicare Oscar/Certification