=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679348056
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CULTURAL LIGHT CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2023
-----------------------------------------------------
Last Update Date | 11/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3638 CAMPBELLTON RD SW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30331-5200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-963-1078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 406 FOREST PKWY STE C
-----------------------------------------------------
City | FOREST PARK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30297-2190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-867-1975
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | ALLISON MUHAMMAD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-867-1975
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251V00000X
-----------------------------------------------------
Taxonomy Name | Voluntary or Charitable Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------