Provider Demographics
NPI:1932540903
Name:TRYST PRIVATE HOMECARE INC
Entity type:Organization
Organization Name:TRYST PRIVATE HOMECARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MODUPE
Authorized Official - Middle Name:OLUYEMISI
Authorized Official - Last Name:SALAMI
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:770-598-7558
Mailing Address - Street 1:331 BLACK WILLOW CT
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-6606
Mailing Address - Country:US
Mailing Address - Phone:770-598-7558
Mailing Address - Fax:678-432-5075
Practice Address - Street 1:331 BLACK WILLOW CT
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-6606
Practice Address - Country:US
Practice Address - Phone:770-598-7558
Practice Address - Fax:678-432-5075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA075-R-0884251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care