Healthcare Provider Details

I. General information

NPI: 1104194307
Provider Name (Legal Business Name): HATTIE CLAY OLIVER PCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 12/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 VININGS VINTAGE CIR
MABLETON GA
30126-7208
US

IV. Provider business mailing address

1180 MADISON GREEN LN SW
MABLETON GA
30126-2154
US

V. Phone/Fax

Practice location:
  • Phone: 770-575-0582
  • Fax: 404-756-4894
Mailing address:
  • Phone: 770-575-0582
  • Fax: 404-756-4894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberPCH005570
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberPCH005570
License Number StateGA

VIII. Authorized Official

Name: MR. JAMES C FORD
Title or Position: CEO
Credential:
Phone: 770-575-0582