Healthcare Provider Details

I. General information

NPI: 1679087274
Provider Name (Legal Business Name): MISTY SUE'S ADULT DAY HEALTH CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2017
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 HILL ST
MONROE GA
30656-1507
US

IV. Provider business mailing address

517 HILL ST
MONROE GA
30656-1507
US

V. Phone/Fax

Practice location:
  • Phone: 770-267-7995
  • Fax:
Mailing address:
  • Phone: 770-267-7995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberADC00203
License Number StateGA

VIII. Authorized Official

Name: NATASHA SHORT
Title or Position: OWNER/OPERATOR
Credential:
Phone: 678-986-4042