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General NPI Number Information
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NPI Number | 1679889307
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Entity Type | Organization
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Legal Business Name | ST. BENEDICT PERSONAL CARE HOME, INC.
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Dates
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Enumeration Date | 08/18/2010
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Last Update Date | 08/18/2010
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Provider Practice Location Address
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Address Line | 1130 VONDA LN SW
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City | MABLETON
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State | GA
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Zip | 30126-3024
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Country | US
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Telephone | 678-401-4788
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Fax | 678-401-4786
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Provider Business Mailing Address
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Address Line | 1130 VONDA LN SW
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City | MABLETON
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State | GA
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Zip | 30126-3024
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Country | US
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Telephone | 678-401-4788
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Fax | 678-401-4786
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Authorized Official
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Title or Position | OWNER
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Name | MRS. CASSANDRA FREEMAN
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Credential | B.A.
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Telephone | 678-401-4788
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 033012821
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License Number State | GA
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