Healthcare Provider Details

I. General information

NPI: 1215592431
Provider Name (Legal Business Name): EGO IDEAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4484 COVINGTON HWY
DECATUR GA
30035-1203
US

IV. Provider business mailing address

3574 COLUMBIA PKWY
DECATUR GA
30034-3349
US

V. Phone/Fax

Practice location:
  • Phone: 678-705-9527
  • Fax:
Mailing address:
  • Phone: 678-705-9527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: CHARLES L MILLER
Title or Position: CFO
Credential:
Phone: 678-705-9527