MEDICARE: ETERNAL HOPE AND LIFE, LLC

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	3104A0625X	Assisted Living Facility (Mental Illness)	060013798	GA
2	3104A0630X	Assisted Living Facility (Behavioral Disturbances)	060013798	GA
3	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	060013798	GA

General Provider Information

NPI Number	:	1477855930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETERNAL HOPE AND LIFE, LLC

Provider Business Mailing Address
First Line	:	2045 MOUNT ZION RD # 337
Second Line	:
City	:	MORROW
State	:	GA
Zip	:	30260-3313
Country	:	US
Telephone Number	:	404-591-5131
Fax Number	:	404-420-2483

Provider Business Practice Location Address
First Line	:	7349 POPPY WAY
Second Line	:
City	:	UNION CITY
State	:	GA
Zip	:	30291-3411
Country	:	US
Telephone Number	:	404-591-5131
Fax Number	:	404-420-2483

Authorized Official
Title or Position	:	CEO
Name	:	MR. RYAN DENNARD
Credential	:
Telephone Number	:	404-591-5131

Provider Enumeration Date	:	12/03/2010
Last Update Date	:	12/03/2010

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