Healthcare Provider Details

I. General information

NPI: 1124353263
Provider Name (Legal Business Name): PERDUM ASSISTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 10/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 KING ARTHUR LN
ELLENWOOD GA
30294-6544
US

IV. Provider business mailing address

5100 KING ARTHUR LN
ELLENWOOD GA
30294-6544
US

V. Phone/Fax

Practice location:
  • Phone: 404-219-3592
  • Fax:
Mailing address:
  • Phone: 404-219-3592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. CYNTHIA PERDUM
Title or Position: DIRECTOR
Credential:
Phone: 404-219-3592