MEDICARE: HAPEVILLE MANOR ASSISTED LIVING FACILITY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility	060030111	GA
2	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	060030111	GA

General Provider Information

NPI Number	:	1083982797
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAPEVILLE MANOR ASSISTED LIVING FACILITY, INC

Provider Business Mailing Address
First Line	:	3752 PRESCOTT RIDGE CIR
Second Line	:
City	:	CLARKSTON
State	:	GA
Zip	:	30021-1664
Country	:	US
Telephone Number	:	404-767-5874
Fax Number	:	404-305-9461

Provider Business Practice Location Address
First Line	:	601 COLEMAN ST
Second Line	:
City	:	HAPEVILLE
State	:	GA
Zip	:	30354-1041
Country	:	US
Telephone Number	:	404-767-5874
Fax Number	:	404-305-9461

Authorized Official
Title or Position	:	CEO
Name	:	MR. CARLTON S. WATT
Credential	:
Telephone Number	:	404-767-5874

Provider Enumeration Date	:	12/08/2011
Last Update Date	:	12/08/2011

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