=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760714299
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECTRUM HABILITATION SERVICE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2010
-----------------------------------------------------
Last Update Date | 02/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 MAGNOLIA WALK LANE
-----------------------------------------------------
City | COLLEGE PARK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-276-2222
-----------------------------------------------------
Fax | 404-691-4354
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 MAGNOLIA WALK LN
-----------------------------------------------------
City | COLLEGE PARK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30349-4072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 404-691-4354
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. LYDIA JACKSON-SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-276-2222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------