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General NPI Number Information
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NPI Number | 1023341062
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Entity Type | Organization
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Legal Business Name | SHIRLEY HOME AWAY FROM HOME
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Dates
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Enumeration Date | 09/09/2009
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Last Update Date | 09/09/2009
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Provider Practice Location Address
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Address Line | 8412 RED CEDAR WAY
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City | RIVERDALE
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State | GA
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Zip | 30274-4562
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Country | US
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Telephone | 678-557-2207
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Fax |
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Provider Business Mailing Address
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Address Line | 8412 RED CEDAR WAY
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City | RIVERDALE
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State | GA
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Zip | 30274-4562
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ADMINISTOR
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Name | SHIRLEY WILSON
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Credential |
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Telephone | 678-557-2207
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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