Provider Demographics
NPI:1962813162
Name:NINE SKY LLC
Entity type:Organization
Organization Name:NINE SKY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAEJIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-447-4898
Mailing Address - Street 1:6000 LIVE OAK PKWY
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-1732
Mailing Address - Country:US
Mailing Address - Phone:770-447-4898
Mailing Address - Fax:
Practice Address - Street 1:6000 LIVE OAK PKWY
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-1732
Practice Address - Country:US
Practice Address - Phone:770-447-4898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-12
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA068505679A385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA068505679AMedicaid