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General NPI Number Information
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NPI Number | 1760670467
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Entity Type | Organization
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Legal Business Name | CLAYTON MHDDAD
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Dates
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Enumeration Date | 10/09/2007
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Last Update Date | 11/08/2011
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Provider Practice Location Address
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Address Line | 9698 HOLLY HILL WAY
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City | JONESBORO
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State | GA
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Zip | 30238-6490
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Country | US
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Telephone | 770-471-2971
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Fax | 770-477-9772
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Provider Business Mailing Address
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Address Line | 157 SMITH ST
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City | JONESBORO
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State | GA
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Zip | 30236-3546
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Country | US
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Telephone | 770-478-2280
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Fax | 770-477-9772
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Authorized Official
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Title or Position | EXCUTIVE DIRECTOR
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Name | MR. TERRY COLE
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Credential |
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Telephone | 770-478-2280
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 385H00000X
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Taxonomy Name | Respite Care
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License Number |
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License Number State |
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