Basic Information
| Provider Information | |||||||||
| NPI: | 1265410633 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ARCHBOLD HEALTH SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ARCHBOLD HOME HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 620 | ||||||||
| Address2: | |||||||||
| City: | THOMASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317990620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292282200 | ||||||||
| FaxNumber: | 2292282290 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 OLD ALBANY ROAD | ||||||||
| Address2: | |||||||||
| City: | THOMASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317924013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292282200 | ||||||||
| FaxNumber: | 2292282290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MUSTIAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | PERRY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2292282042 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ARCHBOLD HEALTH SERVICES, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 20143096 | FL | N | Agencies | Home Health | 251E00000X | 136037 | GA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 000041247A | 05 | GA | MEDICAID | 000041247B | 01 | GA | CCSP (MEDICAID WAIVERED) | OTHER |