=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316209083
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELKS AIDMORE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2012
-----------------------------------------------------
Last Update Date | 06/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2394 MORRISON RD SW
-----------------------------------------------------
City | CONYERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30094-3330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-483-3535
-----------------------------------------------------
Fax | 770-483-5696
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2394 MORRISON RD SW
-----------------------------------------------------
City | CONYERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30094-3330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-483-3535
-----------------------------------------------------
Fax | 770-483-5696
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. ABE MEYER WILKINSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-483-3535
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253J00000X
-----------------------------------------------------
Taxonomy Name | Foster Care Agency
-----------------------------------------------------
License Number | C1000Q010056
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------