Basic Information
| Provider Information | |||||||||
| NPI: | 1265158083 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MLH HEALTHSOURCE | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 514 W OGLETHORPE BLVD # 1010 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317012838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546149001 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 514 W OGLETHORPE BLVD # 1010 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317012838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546149001 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2022 | ||||||||
| LastUpdateDate: | 10/13/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HELTON | ||||||||
| AuthorizedOfficialFirstName: | MONICA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9546149001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NURSE PRACTITIONER | ||||||||
| NPICertificationDate: | 10/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X | Y | Agencies | In Home Supportive Care |
No ID Information.