Healthcare Provider Details

I. General information

NPI: 1174868707
Provider Name (Legal Business Name): HOUSEHOLD OF FAITH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2012
Last Update Date: 12/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 OLD GRIFFIN RD
JACKSON GA
30233-4952
US

IV. Provider business mailing address

341 OLD GRIFFIN RD P.O BOX1804
JACKSON GA
30233-4952
US

V. Phone/Fax

Practice location:
  • Phone: 678-774-8033
  • Fax:
Mailing address:
  • Phone: 678-774-8033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateGA

VIII. Authorized Official

Name: MRS. ANGELA MILLER
Title or Position: EXCUTIVE DIRECTOR
Credential:
Phone: 678-774-8033