Provider Demographics
NPI:1063424752
Name:GEORGIA IN HOME SUPPORT SERVICES
Entity type:Organization
Organization Name:GEORGIA IN HOME SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANTEL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FORSTALL
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:678-817-7338
Mailing Address - Street 1:155 ZELKOVA DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-2528
Mailing Address - Country:US
Mailing Address - Phone:678-817-7338
Mailing Address - Fax:
Practice Address - Street 1:155 ZELKOVA DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-2528
Practice Address - Country:US
Practice Address - Phone:678-817-7338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056-R-0260251J00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251J00000XAgenciesNursing Care
Not Answered251E00000XAgenciesHome Health