Healthcare Provider Details

I. General information

NPI: 1730255167
Provider Name (Legal Business Name): FULTON COUNTY MHDDAD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 LANGHORN ST SW
ATLANTA GA
30310-1627
US

IV. Provider business mailing address

425 LANGHORN ST SW
ATLANTA GA
30310-1627
US

V. Phone/Fax

Practice location:
  • Phone: 404-752-8799
  • Fax:
Mailing address:
  • Phone: 404-752-8799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: LATANGELA KENDRICK
Title or Position: HR SPECIALIST
Credential:
Phone: 404-752-8766