Provider Demographics
NPI:1053287698
Name:MOSSY OAK PERSONAL CARE HOME LLC
Entity type:Organization
Organization Name:MOSSY OAK PERSONAL CARE HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HIRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-294-2837
Mailing Address - Street 1:1150 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31546-1303
Mailing Address - Country:US
Mailing Address - Phone:912-588-0065
Mailing Address - Fax:
Practice Address - Street 1:1150 RIVER RD
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31546-1303
Practice Address - Country:US
Practice Address - Phone:912-588-0065
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-13
Last Update Date:2025-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care