Healthcare Provider Details

I. General information

NPI: 1780953018
Provider Name (Legal Business Name): DADE COMMUNITY LIVING ARRANGEMENT (CLA)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2011
Last Update Date: 12/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1289 MACEDONIA CHURCH RD.
OXFORD GA
30054-3651
US

IV. Provider business mailing address

1289 MACEDONIA CHURCH RD.
OXFORD GA
30054-3651
US

V. Phone/Fax

Practice location:
  • Phone: 678-660-3339
  • Fax: 770-679-5670
Mailing address:
  • Phone: 678-660-3339
  • Fax: 770-679-5670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number10701-081-1
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberCN0028872680
License Number StateGA

VIII. Authorized Official

Name: MRS. DIAN EVADNE WALTERS-MOTT
Title or Position: OWNER/DIRECTOR
Credential:
Phone: 678-768-5997