=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023550407
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMELIA GARDENS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2016
-----------------------------------------------------
Last Update Date | 11/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 576 NICKAJACK RD SW
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126-1419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-712-4903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 576 NICKAJACK RD SW
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126-1419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-712-4903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. ISOKEN J ONAIWU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-712-4903
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 033-02-028-1
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------