Healthcare Provider Details

I. General information

NPI: 1134564131
Provider Name (Legal Business Name): PANOLA CARE, CLA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2013
Last Update Date: 05/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3169 PEQUEA DR
LITHONIA GA
30038-1119
US

IV. Provider business mailing address

3169 PEQUEA DR
LITHONIA GA
30038-1119
US

V. Phone/Fax

Practice location:
  • Phone: 770-322-6810
  • Fax: 770-322-6810
Mailing address:
  • Phone: 770-322-6810
  • Fax:

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 Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MISS CAROL A TAVARES
Title or Position: DIRECTOR
Credential:
Phone: 770-322-6810