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General NPI Number Information
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NPI Number | 1316221815
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Entity Type | Organization
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Legal Business Name | AIDEN'S PLACE, LLC
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Dates
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Enumeration Date | 10/03/2011
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Last Update Date | 10/03/2011
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Provider Practice Location Address
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Address Line | 7370 WRIGHT DR
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City | ATLANTA
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State | GA
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Zip | 30349-7911
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Country | US
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Telephone | 770-573-1076
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Fax | 770-234-5894
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Provider Business Mailing Address
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Address Line | 1227 ROCKBRIDGE RD SUITE 208-196
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City | STONE MOUNTAIN
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State | GA
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Zip | 30087-3064
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Country | US
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Telephone | 770-573-1076
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Fax | 770-234-5894
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Authorized Official
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Title or Position | CEO
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Name | RONDINE D GORDON
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Credential |
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Telephone | 770-573-1076
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 | PCH008079
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License Number State | GA
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Taxonomy #2
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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 | PCH008079
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License Number State | GA
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