MEDICARE: D & J SUPERIOR COMMUNITY LIVING

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1588971550
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	D & J SUPERIOR COMMUNITY LIVING

Provider Business Mailing Address
First Line	:	2579 PIERCE CIR
Second Line	:
City	:	SNELLVILLE
State	:	GA
Zip	:	30078-5768
Country	:	US
Telephone Number	:	770-871-5630
Fax Number	:	678-691-3269

Provider Business Practice Location Address
First Line	:	2579 PIERCE CIR
Second Line	:
City	:	SNELLVILLE
State	:	GA
Zip	:	30078-5768
Country	:	US
Telephone Number	:	770-871-5630
Fax Number	:	678-691-3269

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. SHAWN GRADY
Credential	:
Telephone Number	:	770-905-2067

Provider Enumeration Date	:	09/10/2010
Last Update Date	:	09/10/2010

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