Healthcare Provider Details

I. General information

NPI: 1841619269
Provider Name (Legal Business Name): COTTAGE ADULT DAY SERVICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1142 ATHENS HWY
GRAYSON GA
30017-1709
US

IV. Provider business mailing address

1142 ATHENS HWY
GRAYSON GA
30017-1709
US

V. Phone/Fax

Practice location:
  • Phone: 770-978-9696
  • Fax:
Mailing address:
  • Phone: 770-978-9696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number14000773
License Number StateGA

VIII. Authorized Official

Name: KATINA LAC KHAN
Title or Position: OWNER
Credential:
Phone: 770-978-9696