=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083996292
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TERRELL'S PERSONAL CARE HOME, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2011
-----------------------------------------------------
Last Update Date | 09/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5100 ATLANTA HWY 5150 ATLANTA HIGHWAY
-----------------------------------------------------
City | BOGART
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30622-2109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-338-5091
-----------------------------------------------------
Fax | 866-615-7091
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 126 BARRINGTON DR
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30605-3580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-338-5091
-----------------------------------------------------
Fax | 866-615-7091
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM MANAGER
-----------------------------------------------------
Name | MRS. ANDRICK TERRELL-MOON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-338-5091
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------