Provider Demographics
NPI:1285390716
Name:HIAWATHA PRIVATE HEALTHCARE SERVICE, LLC
Entity type:Organization
Organization Name:HIAWATHA PRIVATE HEALTHCARE SERVICE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:HIAWATHA
Authorized Official - Middle Name:VENNESSA
Authorized Official - Last Name:RAINEY
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:706-306-0091
Mailing Address - Street 1:3424 KENSINGTON DR S
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-6002
Mailing Address - Country:US
Mailing Address - Phone:706-306-0091
Mailing Address - Fax:706-796-0261
Practice Address - Street 1:3424 KENSINGTON DR S
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-6002
Practice Address - Country:US
Practice Address - Phone:706-306-0091
Practice Address - Fax:706-796-0261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-09
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA253Z00000XOtherPRIVATE HOME CARE PROVIDER
GA251E00000XOtherPRIVATE HOME CARE PROVIDER
GA251X00000XOtherPRIVATE HOME CARE PROVIDER
GA251J00000XOtherPRIVATE HOME CARE PROVIDER