Healthcare Provider Details

I. General information

NPI: 1407158231
Provider Name (Legal Business Name): MCKNIGHT PERSONAL CARE HOME INC,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2010
Last Update Date: 11/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3045 CARRIAGE TRL
JONESBORO GA
30236-6835
US

IV. Provider business mailing address

3045 CARRIAGE TRL
JONESBORO GA
30236-6835
US

V. Phone/Fax

Practice location:
  • Phone: 678-519-2115
  • Fax: 678-216-0311
Mailing address:
  • Phone: 678-519-2115
  • Fax: 678-216-0311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: SHANTERIA LASHUN MCKNIGHT
Title or Position: DIRECTOR
Credential:
Phone: 678-643-3600