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General NPI Number Information
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NPI Number | 1306105812
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Entity Type | Organization
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Legal Business Name | FREEDOM REST OF KENNESAW LLC
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Dates
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Enumeration Date | 05/04/2012
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Last Update Date | 05/04/2012
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Provider Practice Location Address
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Address Line | 3351 OWENS BROOK WAY NW
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City | KENNESAW
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State | GA
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Zip | 30152-2566
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Country | US
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Telephone | 770-693-0863
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Fax | 770-693-0863
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Provider Business Mailing Address
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Address Line | 3351 OWENS BROOK WAY NW
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City | KENNESAW
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State | GA
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Zip | 30152-2566
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Country | US
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Telephone | 770-693-0863
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Fax | 770-693-0863
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Authorized Official
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Title or Position | DIRECTOR
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Name | MRS. YOLANDA LETICE WILSON
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Credential |
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Telephone | 678-499-6426
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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 | PCH006452
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License Number State | GA
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