MEDICARE: THE NATHANIEL WATSON, JR. MEMORIAL FOUNDATION, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3140N1450X	Pediatric Skilled Nursing Facility		GA
2	251G00000X	Community Based Hospice Care Agency

General Provider Information

NPI Number	:	1003845967
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE NATHANIEL WATSON, JR. MEMORIAL FOUNDATION, INC

Provider Business Mailing Address
First Line	:	506 CALGARY GLEN DRIVE SW
Second Line	:
City	:	AUSTELL
State	:	GA
Zip	:	30168-7284
Country	:	US
Telephone Number	:	770-732-9196
Fax Number	:	770-770-0739

Provider Business Practice Location Address
First Line	:	506 CALGARY GLEN DRIVE SW
Second Line	:
City	:	AUSTELL
State	:	GA
Zip	:	30168-7284
Country	:	US
Telephone Number	:	770-770-9196
Fax Number	:	770-732-0739

Authorized Official
Title or Position	:	CEO
Name	:	MS. VALERIE WATSON-BAXTER
Credential	:
Telephone Number	:	770-693-8852

Provider Enumeration Date	:	07/02/2006
Last Update Date	:	09/09/2008

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