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General NPI Number Information
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NPI Number | 1144521428
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Entity Type | Organization
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Legal Business Name | KELLY'S LIFE CENTER
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Dates
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Enumeration Date | 11/03/2010
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Last Update Date | 11/03/2010
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Provider Practice Location Address
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Address Line | 3895 TOLLIVER HILLS DR
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City | ELLENWOOD
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State | GA
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Zip | 30294-1209
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Country | US
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Telephone | 404-228-7985
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Fax | 404-963-7812
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Provider Business Mailing Address
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Address Line | 1616 COLUMBIA DR
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City | DECATUR
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State | GA
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Zip | 30032-4613
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Country | US
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Telephone | 404-228-7985
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Fax | 404-963-7812
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Authorized Official
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Title or Position | OWNER
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Name | TERESSA DOUGLAS
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Credential |
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Telephone | 404-228-7985
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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 | 031012958
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | 031012958
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License Number State | GA
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