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General NPI Number Information
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NPI Number | 1083966428
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Entity Type | Organization
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Legal Business Name | TRULY LIVING WELL PCH, LLC
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Dates
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Enumeration Date | 10/09/2012
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Last Update Date | 10/09/2012
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Provider Practice Location Address
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Address Line | 7078 BETHEL CT
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City | RIVERDALE
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State | GA
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Zip | 30296-2152
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Country | US
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Telephone | 678-519-4984
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Fax |
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Provider Business Mailing Address
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Address Line | 326 RIDGE TRL
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City | RIVERDALE
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State | GA
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Zip | 30274-1954
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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 | OWNER
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Name | JEANNIE CASEY
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Credential |
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Telephone | 678-451-2890
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 031011731
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License Number State | GA
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