Healthcare Provider Details

I. General information

NPI: 1851840797
Provider Name (Legal Business Name): THE ELIM COMMUNITY DEVELOPMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 10/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4717 COVINGTON HWY SUITE 109
DECATUR GA
30035-2015
US

IV. Provider business mailing address

2714 WATERFORD CLUB DR
LITHIA SPRINGS GA
30122-4413
US

V. Phone/Fax

Practice location:
  • Phone: 470-658-9284
  • Fax:
Mailing address:
  • Phone: 470-658-9284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. OSBORNE J GILES SR.
Title or Position: CEO
Credential:
Phone: 470-658-9284