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General NPI Number Information
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NPI Number | 1104194307
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Entity Type | Organization
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Legal Business Name | HATTIE CLAY OLIVER PCH
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Dates
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Enumeration Date | 12/02/2011
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Last Update Date | 12/06/2011
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Provider Practice Location Address
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Address Line | 418 VININGS VINTAGE CIR
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City | MABLETON
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State | GA
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Zip | 30126-7208
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Country | US
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Telephone | 770-575-0582
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Fax | 404-756-4894
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Provider Business Mailing Address
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Address Line | 1180 MADISON GREEN LN SW
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City | MABLETON
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State | GA
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Zip | 30126-2154
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Country | US
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Telephone | 770-575-0582
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Fax | 404-756-4894
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Authorized Official
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Title or Position | CEO
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Name | MR. JAMES C FORD
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Credential |
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Telephone | 770-575-0582
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | PCH005570
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | PCH005570
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License Number State | GA
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