Provider Demographics
NPI:1194598185
Name:HAVEN HOSPICE AND PALLIATIVE CARE OF GEORGIA, LLC
Entity type:Organization
Organization Name:HAVEN HOSPICE AND PALLIATIVE CARE OF GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JERI
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-882-8174
Mailing Address - Street 1:2900 CHAMBLEE TUCKER RD
Mailing Address - Street 2:BLDG 14, SUITE 250
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341
Mailing Address - Country:US
Mailing Address - Phone:770-882-8174
Mailing Address - Fax:
Practice Address - Street 1:2900 CHAMBLEE TUCKER RD
Practice Address - Street 2:BLDG 14, SUITE 250
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341
Practice Address - Country:US
Practice Address - Phone:770-882-8174
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based