Provider Demographics
NPI:1306468228
Name:MASALON PERSONAL CARE HOME INC.
Entity type:Organization
Organization Name:MASALON PERSONAL CARE HOME INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAKESA
Authorized Official - Middle Name:MAMIE
Authorized Official - Last Name:FOFANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-826-4317
Mailing Address - Street 1:3952 ROCKBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-4170
Mailing Address - Country:US
Mailing Address - Phone:917-826-4317
Mailing Address - Fax:
Practice Address - Street 1:3952 ROCKBRIDGE RD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-4170
Practice Address - Country:US
Practice Address - Phone:917-826-4317
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty