MEDICARE: GOD'S CHILD PERSONAL CARE HOME LLC

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1144559550
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOD'S CHILD PERSONAL CARE HOME LLC

Provider Business Mailing Address
First Line	:	4810 ENCLAVE DR
Second Line	:
City	:	UNION CITY
State	:	GA
Zip	:	30291-6072
Country	:	US
Telephone Number	:	810-875-8255
Fax Number	:

Provider Business Practice Location Address
First Line	:	4810 ENCLAVE DR
Second Line	:
City	:	UNION CITY
State	:	GA
Zip	:	30291-6072
Country	:	US
Telephone Number	:	810-875-8255
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	DAVID SMITH
Credential	:
Telephone Number	:	810-875-8255

Provider Enumeration Date	:	12/14/2009
Last Update Date	:	12/14/2009

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