Healthcare Provider Details

I. General information

NPI: 1750682571
Provider Name (Legal Business Name): INTIMATE ESTATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2010
Last Update Date: 11/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 WOMACK RD
COVINGTON GA
30016-1882
US

IV. Provider business mailing address

449 WOMACK RD
COVINGTON GA
30016-1882
US

V. Phone/Fax

Practice location:
  • Phone: 678-279-5400
  • Fax: 678-279-5470
Mailing address:
  • Phone: 678-279-5400
  • Fax: 678-279-5470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number107030049
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number107030049
License Number StateGA

VIII. Authorized Official

Name: MRS. CAROL BELGRAVE
Title or Position: CEO
Credential:
Phone: 678-279-5400