Healthcare Provider Details

I. General information

NPI: 1417258732
Provider Name (Legal Business Name): ATLEMISIA ANDERSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2010
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 GLEN ARVEN DR
THOMASVILLE GA
31792-6837
US

IV. Provider business mailing address

117 WILLOW RIDGE CIR
THOMASVILLE GA
31757-2834
US

V. Phone/Fax

Practice location:
  • Phone: 229-379-1007
  • Fax:
Mailing address:
  • Phone: 229-379-1007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
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: ATLEMISIA M ANDERSON
Title or Position: OWNER
Credential:
Phone: 229-379-1007