Healthcare Provider Details

I. General information

NPI: 1730457458
Provider Name (Legal Business Name): GEORGIA COMMUNITY LIVING FACILITIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 03/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 LANIER AVE W STE 610
FAYETTEVILLE GA
30214-7644
US

IV. Provider business mailing address

500 LANIER AVE W STE 610
FAYETTEVILLE GA
30214-7644
US

V. Phone/Fax

Practice location:
  • Phone: 404-829-2715
  • Fax: 678-817-5909
Mailing address:
  • Phone: 404-829-2715
  • Fax: 678-817-5909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number007876
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number007874
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: MS. RHONDA ANN CROCKETT
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 404-829-2715