Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 CALGARY GLEN DRIVE SW
AUSTELL GA
30168-7284
US

IV. Provider business mailing address

506 CALGARY GLEN DRIVE SW
AUSTELL GA
30168-7284
US

V. Phone/Fax

Practice location:
  • Phone: 770-770-9196
  • Fax: 770-732-0739
Mailing address:
  • Phone: 770-732-9196
  • Fax: 770-770-0739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number
License Number StateGA

VIII. Authorized Official

Name: MS. VALERIE WATSON-BAXTER
Title or Position: CEO
Credential:
Phone: 770-693-8852