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General NPI Number Information
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NPI Number | 1710683396
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Entity Type | Organization
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Legal Business Name | WILLIE B GARDNER ASSISTED LIVING INC.
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Dates
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Enumeration Date | 02/06/2023
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Last Update Date | 02/06/2023
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Provider Practice Location Address
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Address Line | 1262 KING RD
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City | RIVERDALE
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State | GA
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Zip | 30296-2952
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Country | US
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Telephone | 678-789-5174
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Fax |
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Provider Business Mailing Address
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Address Line | 1262 KING RD
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City | RIVERDALE
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State | GA
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Zip | 30296-2952
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Country | US
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Telephone | 678-789-5174
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | SHAURINA S. DUDLEY
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Credential |
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Telephone | 678-663-9674
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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 |
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License Number State |
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