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General NPI Number Information
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NPI Number | 1629207733
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Entity Type | Organization
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Legal Business Name | SOUTHERN INTERNATIONAL LIVING, INC
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Dates
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Enumeration Date | 07/09/2009
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Last Update Date | 05/12/2012
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Provider Practice Location Address
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Address Line | 3437 MOUNT OLIVE RD
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City | EAST POINT
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State | GA
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Zip | 30344-5812
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Country | US
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Telephone | 404-547-1291
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Fax | 404-551-3549
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Provider Business Mailing Address
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Address Line | 3437 MOUNT OLIVE RD
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City | EAST POINT
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State | GA
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Zip | 30344-5812
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Country | US
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Telephone | 404-684-6884
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Fax | 404-551-3549
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Authorized Official
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Title or Position | DIRECTOR
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Name | MRS. MINNIE LEE WARD
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Credential | CNA
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Telephone | 404-684-6884
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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 | CLA000974
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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 | CLA001010
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License Number State | GA
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