Healthcare Provider Details

I. General information

NPI: 1578190450
Provider Name (Legal Business Name): FOUR-SIXTY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 MARTHA BERRY HWY NE
ROME GA
30165-8642
US

IV. Provider business mailing address

460 BERKSHIRE PL
FAIRBURN GA
30213-2069
US

V. Phone/Fax

Practice location:
  • Phone: 678-834-7615
  • Fax:
Mailing address:
  • Phone: 832-454-8506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code315D00000X
TaxonomyInpatient Hospice
License Number
License Number State

VIII. Authorized Official

Name: MR. NORWOOD N RICHARDSON
Title or Position: OWNER
Credential: ESQ
Phone: 832-454-8506