Mystique Homecare Agency

Primary specialty

In Home Supportive Care AgencyTaxonomy code 253Z00000X

Legal business name

MYSTIQUE HOMECARE AGENCY

Practice address

3675 Crestwood Pkwy NW Ste 400
Duluth, GA 30096-5054

Phone

(470) 509-5533

Fax

(470) 625-3368

NPI assigned

Jul 1, 2020

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Bukola Sholanke

Title

Administrator

Phone

(470) 509-5533

Specialties & licenses 2

Addresses

Electronic endpoints 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1593561600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1602288000000",
    "number": "1750908018",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3675 CRESTWOOD PKWY NW STE 400",
            "city": "DULUTH",
            "state": "GA",
            "postal_code": "300965054",
            "telephone_number": "470-509-5533",
            "fax_number": "470-625-3368"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3675 CRESTWOOD PKWY NW STE 400",
            "city": "DULUTH",
            "state": "GA",
            "postal_code": "300965054",
            "telephone_number": "470-509-5533",
            "fax_number": "470-625-3368"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MYSTIQUE HOMECARE AGENCY",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-07-01",
        "last_updated": "2020-10-10",
        "certification_date": "2020-10-10",
        "status": "A",
        "authorized_official_last_name": "SHOLANKE",
        "authorized_official_first_name": "BUKOLA",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "470-509-5533"
    },
    "taxonomies": [
        {
            "code": "251G00000X",
            "taxonomy_group": "",
            "desc": "Hospice Care, Community Based",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "253Z00000X",
            "taxonomy_group": "",
            "desc": "In Home Supportive Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "www.mystiquehca.com",
            "affiliation": "N",
            "address_1": "3675 Crestwood Pkwy NW Ste 400",
            "city": "Duluth",
            "state": "GA",
            "country_code": "US",
            "postal_code": "300965054",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 10, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.