Basic Information
| Provider Information | |||||||||
| NPI: | 1225047087 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMBRACING HOSPICE CARE OF SOUTH ATLANTA,LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EMBRACING HOSICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 N LAURA ST | ||||||||
| Address2: | STE 1800 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322023664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044936745 | ||||||||
| FaxNumber: | 9042624804 | ||||||||
| Practice Location | |||||||||
| Address1: | 2340 PATRICK HENRY PKWY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302534325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789612170 | ||||||||
| FaxNumber: | 6789612161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 09/13/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FOGLE | ||||||||
| AuthorizedOfficialFirstName: | RICH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9044936745 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 067161H | GA | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 00965258A | 05 | GA | MEDICAID |