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General NPI Number Information
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NPI Number | 1033506712
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Entity Type | Organization
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Legal Business Name | ST. MARY'S INDEPENDENT LIVING EXTENSIONS
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Dates
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Enumeration Date | 04/21/2015
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Last Update Date | 04/21/2015
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Provider Practice Location Address
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Address Line | 120 GLOSTER RD NW STE 3
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City | LAWRENCEVILLE
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State | GA
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Zip | 30044-4479
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Country | US
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Telephone | 770-279-5115
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Fax | 770-923-2059
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Provider Business Mailing Address
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Address Line | 120 GLOSTER RD NW STE 3
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City | LAWRENCEVILLE
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State | GA
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Zip | 30044-4479
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Country | US
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Telephone | 770-279-5115
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Fax | 770-923-2059
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | PAUL PIEPER
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Credential |
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Telephone | 770-279-5115
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number | 067-R-0388
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License Number State | GA
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