Healthcare Provider Details

I. General information

NPI: 1811369192
Provider Name (Legal Business Name): S. ELLIS ADULT DAYCARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2015
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 SALEM GATE DRIVE
CONYERS GA
30013-1362
US

IV. Provider business mailing address

1229 SALEM GATE DRIVE
CONYERS GA
30013-1362
US

V. Phone/Fax

Practice location:
  • Phone: 770-679-4503
  • Fax: 888-273-6606
Mailing address:
  • Phone: 770-679-4503
  • Fax: 888-273-6606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateGA

VIII. Authorized Official

Name: MRS. SELINA Y ELLIS
Title or Position: OWNER/DIRECTOR
Credential:
Phone: 770-679-4503