Provider Demographics
NPI:1588061469
Name:YAY GOD BOO DEVIL LLC
Entity type:Organization
Organization Name:YAY GOD BOO DEVIL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CARROLL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:706-231-5552
Mailing Address - Street 1:1801 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-5316
Mailing Address - Country:US
Mailing Address - Phone:706-231-5552
Mailing Address - Fax:
Practice Address - Street 1:321 WASHINGTON COMMONS DR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3170
Practice Address - Country:US
Practice Address - Phone:706-231-5552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN113796251J00000X, 163WR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WR0400XNursing Service ProvidersRegistered NurseRehabilitationGroup - Single Specialty
No251J00000XAgenciesNursing CareGroup - Single Specialty