=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063990778
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIRST SENIOR CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2018
-----------------------------------------------------
Last Update Date | 08/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7116 PEACHTREE INDUSTRIAL BLVD BLDG 4
-----------------------------------------------------
City | PEACHTREE CORNERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-289-2222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7116 PEACHTREE INDUSTRIAL BLVD BLDG 4
-----------------------------------------------------
City | PEACHTREE CORNERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-289-2222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | VAN TRAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-289-2665
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number | ADC000183
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------