Provider Demographics
NPI:1730787136
Name:LUCIENNE HOME CARE LLC
Entity type:Organization
Organization Name:LUCIENNE HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUCIENNE
Authorized Official - Middle Name:B
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:167-878-9073
Mailing Address - Street 1:2407 HI ROC RD NE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-2541
Mailing Address - Country:US
Mailing Address - Phone:177-028-5667
Mailing Address - Fax:
Practice Address - Street 1:2407 HI ROC RD NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-2541
Practice Address - Country:US
Practice Address - Phone:177-028-5667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPHCP010882Medicaid