Healthcare Provider Details

I. General information

NPI: 1578756532
Provider Name (Legal Business Name): THE KIYA HOUSE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 08/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1256 HIGHWAY 138 SW
RIVERDALE GA
30296-1402
US

IV. Provider business mailing address

1256 HIGHWAY 138 SW
RIVERDALE GA
30296-1402
US

V. Phone/Fax

Practice location:
  • Phone: 770-994-2223
  • Fax: 770-994-2224
Mailing address:
  • Phone: 770-994-2223
  • Fax: 770-994-2224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DR. ANGELA DENISE COSBY
Title or Position: CEO/OWNER
Credential:
Phone: 770-994-2223