Provider Demographics
NPI:1063297026
Name:GENTLEMAN HOME CARE
Entity type:Organization
Organization Name:GENTLEMAN HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-943-1442
Mailing Address - Street 1:4586 VALLEY PKWY SE UNITE E
Mailing Address - Street 2:4586 VALLEY PKWY SE UNIT E
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082
Mailing Address - Country:US
Mailing Address - Phone:914-943-1442
Mailing Address - Fax:
Practice Address - Street 1:4586 VALLEY PKWY SE UNITE E
Practice Address - Street 2:4586 VALLEY PKWY SE UNIT E
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082
Practice Address - Country:US
Practice Address - Phone:914-943-1442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0810XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & FamilyGroup - Single Specialty