=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184162091
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FELLOWSHIP ASSISTED LIVING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2017
-----------------------------------------------------
Last Update Date | 02/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 277 MEDICAL WAY
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30274-2522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-909-0221
-----------------------------------------------------
Fax | 770-909-0219
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 277 MEDICAL WAY
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30274-2522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-909-0221
-----------------------------------------------------
Fax | 770-909-0219
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. DOMINIQUE NAAR
-----------------------------------------------------
Credential | 4043767658
-----------------------------------------------------
Telephone | 404-376-7658
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 031-01-241-1
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------