Provider Demographics
NPI:1063712487
Name:GLORY PERSONAL CARE HOME, LLC
Entity type:Organization
Organization Name:GLORY PERSONAL CARE HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SYVIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-342-8818
Mailing Address - Street 1:90 PACES LNDG
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-4167
Mailing Address - Country:US
Mailing Address - Phone:678-432-8818
Mailing Address - Fax:
Practice Address - Street 1:90 PACES LNDG
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-4167
Practice Address - Country:US
Practice Address - Phone:678-432-8818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN 188675385H00000X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty
No385H00000XRespite Care FacilityRespite CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GABLC10-17496OtherNEWTON COUNTY BUSINESS LICENSE
GA107-01-0829OtherGEORGIA DEPARTMENT OF COMMUNITY HEALTH
GARN188675OtherREGISTERED NURSE LICENSE