Healthcare Provider Details

I. General information

NPI: 1700070398
Provider Name (Legal Business Name): CELINE'S FAMILY SERVICE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6440 OLD HILLANDALE DR
LITHONIA GA
30058-7672
US

IV. Provider business mailing address

1417 DOE VALLEY DR
LITHONIA GA
30058-6203
US

V. Phone/Fax

Practice location:
  • Phone: 770-315-5146
  • Fax:
Mailing address:
  • Phone: 770-315-5146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number4279373712500
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number4279373712500
License Number StateGA

VIII. Authorized Official

Name: MRS. SANDRA LEAVELL
Title or Position: EXECUTIVE OFFICER
Credential:
Phone: 770-315-5146