Healthcare Provider Details

I. General information

NPI: 1932472180
Provider Name (Legal Business Name): ROYAL COTTAGE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2012
Last Update Date: 02/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 STONEY POINT TER
COVINGTON GA
30014-7070
US

IV. Provider business mailing address

65 STONEY POINT TER
COVINGTON GA
30014-7070
US

V. Phone/Fax

Practice location:
  • Phone: 678-261-8125
  • Fax:
Mailing address:
  • Phone: 678-261-8125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number107-01-071-1
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number107-01-071-1
License Number StateGA

VIII. Authorized Official

Name: THERESA L REID
Title or Position: CEO
Credential:
Phone: 770-256-3194