Basic Information
| Provider Information | |||||||||
| NPI: | 1871889956 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUNCREST HOME HEALTH-SOUTHSIDE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUNCREST HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6687 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303150687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046881350 | ||||||||
| FaxNumber: | 4046882962 | ||||||||
| Practice Location | |||||||||
| Address1: | 1039 RIDGE AVE SW | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303151601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703932309 | ||||||||
| FaxNumber: | 7706680522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2011 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| AuthorizedOfficialLastName: | AZZARITI | ||||||||
| AuthorizedOfficialFirstName: | CLAUDIO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4045647009 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 044-293H | GA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 003126784A | 05 | GA | MEDICAID |