Healthcare Provider Details

I. General information

NPI: 1255506895
Provider Name (Legal Business Name): KEYSTONE CENTER FOR CHILDREN WITH AUTISM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 HEMBREE RD
ALPHARETTA GA
30004-2083
US

IV. Provider business mailing address

1675 HEMBREE RD
ALPHARETTA GA
30004-2083
US

V. Phone/Fax

Practice location:
  • Phone: 404-496-4673
  • Fax: 404-496-4674
Mailing address:
  • Phone: 404-496-4673
  • Fax: 404-496-4674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS OWEN LANE III
Title or Position: CEO
Credential:
Phone: 404-496-4673