Provider Demographics
NPI:1275428484
Name:MUDARIS HEALTHCARE LLC
Entity type:Organization
Organization Name:MUDARIS HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:DERRICOTTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-420-3010
Mailing Address - Street 1:1300 RIDENOUR BLVD NW STE 100
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4528
Mailing Address - Country:US
Mailing Address - Phone:470-995-1258
Mailing Address - Fax:
Practice Address - Street 1:4590 VALLEY PKWY SE APT E
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-4981
Practice Address - Country:US
Practice Address - Phone:646-420-3010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care