Healthcare Provider Details

I. General information

NPI: 1457623308
Provider Name (Legal Business Name): PATRON PLACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2012
Last Update Date: 02/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1227 ROCKBRIDGE RD STE 208-196
STONE MOUNTAIN GA
30087-3064
US

IV. Provider business mailing address

1227 ROCKBRIDGE RD STE 208-196
STONE MOUNTAIN GA
30087-3064
US

V. Phone/Fax

Practice location:
  • Phone: 770-573-1076
  • Fax: 770-234-5894
Mailing address:
  • Phone: 770-573-1076
  • Fax: 770-234-5894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberPCH006520
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License NumberPCH006520
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberPCH006520
License Number StateGA

VIII. Authorized Official

Name: MRS. RONDINE GORDON
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 770-573-1076