MEDICARE: L ALLEN HOST HOME

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1730459074
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	L ALLEN HOST HOME

Provider Business Mailing Address
First Line	:	250 NORTH AVE
Second Line	:
City	:	ATHENS
State	:	GA
Zip	:	30601-2244
Country	:	US
Telephone Number	:	706-389-6789
Fax Number	:

Provider Business Practice Location Address
First Line	:	843 LINCOLN HTS
Second Line	:
City	:	ELBERTON
State	:	GA
Zip	:	30635-2234
Country	:	US
Telephone Number	:	706-408-0418
Fax Number	:

Authorized Official
Title or Position	:	BILLING MGR
Name	:	GLENN BUTLER
Credential	:
Telephone Number	:	706-389-6789

Provider Enumeration Date	:	01/04/2012
Last Update Date	:	01/04/2012

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