Provider Demographics
NPI:1295065175
Name:SOUTHERN CRESCENT HOME CARE
Entity type:Organization
Organization Name:SOUTHERN CRESCENT HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:ONYIBO
Authorized Official - Last Name:MOH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-360-6003
Mailing Address - Street 1:1351 GRINDENWALD DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-8001
Mailing Address - Country:US
Mailing Address - Phone:678-360-6003
Mailing Address - Fax:770-472-0107
Practice Address - Street 1:1351 GRINDENWALD DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30238-8001
Practice Address - Country:US
Practice Address - Phone:678-360-6003
Practice Address - Fax:770-472-0107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-28
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031-R-0360253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA164763686AMedicaid