Healthcare Provider Details

I. General information

NPI: 1386921336
Provider Name (Legal Business Name): CHESTNUT MANOR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8673 CHESTNUT LN
LITHIA SPRINGS GA
30122-3410
US

IV. Provider business mailing address

8673 CHESTNUT LN
LITHIA SPRINGS GA
30122-3410
US

V. Phone/Fax

Practice location:
  • Phone: 770-920-9369
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number12040
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number12040
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number12040
License Number StateGA

VIII. Authorized Official

Name: MRS. SHIRLEY NAPIER-BRADY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 770-920-9369