Provider Demographics
NPI:1215239710
Name:BLACKLAND HOME CARE, LLC
Entity type:Organization
Organization Name:BLACKLAND HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:HANNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-518-9522
Mailing Address - Street 1:177 ENNISBROOK DR SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-2451
Mailing Address - Country:US
Mailing Address - Phone:678-823-8155
Mailing Address - Fax:678-823-8156
Practice Address - Street 1:177 ENNISBROOK DR SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-2451
Practice Address - Country:US
Practice Address - Phone:678-823-8155
Practice Address - Fax:678-823-8156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN 188675251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health