Provider Demographics
NPI:1902059439
Name:COLEMAN & STALLWORTH REAL ESTATE HOLDING, LLC
Entity Type:Organization
Organization Name:COLEMAN & STALLWORTH REAL ESTATE HOLDING, LLC
Other - Org Name:PROFESSIONAL CARE GIVERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:STALLWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-602-0183
Mailing Address - Street 1:4363 AZALEA WALK
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-6552
Mailing Address - Country:US
Mailing Address - Phone:404-244-3292
Mailing Address - Fax:404-244-3414
Practice Address - Street 1:4363 AZALEA WALK
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-6552
Practice Address - Country:US
Practice Address - Phone:404-244-3292
Practice Address - Fax:404-244-3414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044--R-0499251E00000X
GA044-R-0499332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies