Healthcare Provider Details

I. General information

NPI: 1003117615
Provider Name (Legal Business Name): THE MARY WASHINGTON ASSISTED LIVING HOME, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2010
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 MOUNTAIN OAKS PKWY
STONE MOUNTAIN GA
30087-4732
US

IV. Provider business mailing address

590 MOUNTAIN OAKS PKWY
STONE MOUNTAIN GA
30087-4732
US

V. Phone/Fax

Practice location:
  • Phone: 770-469-0155
  • Fax: 770-469-0155
Mailing address:
  • Phone: 770-469-0155
  • Fax: 770-469-0155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number044018141
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number044018141
License Number StateGA

VIII. Authorized Official

Name: MS. TAWANA GRAY
Title or Position: CEO
Credential:
Phone: 770-469-0155