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General NPI Number Information
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NPI Number | 1366752578
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Entity Type | Organization
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Legal Business Name | IJN CHILD & ADULT CARE HOMES
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Dates
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Enumeration Date | 10/21/2010
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Last Update Date | 10/21/2010
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Provider Practice Location Address
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Address Line | 1949 VICKI LANE
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City | ATLANTA
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State | GA
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Zip | 30316-4108
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Country | US
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Telephone | 404-447-0800
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Fax | 404-284-7478
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Provider Business Mailing Address
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Address Line | P.O. BOX 370213
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City | DECATUR
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State | GA
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Zip | 30037-0213
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Country | US
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Telephone | 404-447-0800
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Fax | 404-284-7478
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Authorized Official
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Title or Position | DIRECTOR
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Name | MRS. GINA BLAKE
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Credential |
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Telephone | 404-447-0800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 | 416579002A
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License Number State | GA
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