Provider Demographics
NPI:1750908018
Name:MYSTIQUE HOMECARE AGENCY
Entity type:Organization
Organization Name:MYSTIQUE HOMECARE AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BUKOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOLANKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-509-5533
Mailing Address - Street 1:3675 CRESTWOOD PKWY NW STE 400
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5054
Mailing Address - Country:US
Mailing Address - Phone:470-509-5533
Mailing Address - Fax:470-625-3368
Practice Address - Street 1:3675 CRESTWOOD PKWY NW STE 400
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5054
Practice Address - Country:US
Practice Address - Phone:470-509-5533
Practice Address - Fax:470-625-3368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-01
Last Update Date:2020-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive Care
No251G00000XAgenciesHospice Care, Community BasedGroup - Single Specialty