MEDICARE: S. ELLIS ADULT DAYCARE SERVICES, 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	261QA0600X	Adult Day Care Clinic/Center		GA

General Provider Information

NPI Number	:	1811369192
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	S. ELLIS ADULT DAYCARE SERVICES, LLC

Provider Business Mailing Address
First Line	:	1229 SALEM GATE DRIVE
Second Line	:
City	:	CONYERS
State	:	GA
Zip	:	30013-1362
Country	:	US
Telephone Number	:	770-679-4503
Fax Number	:	888-273-6606

Provider Business Practice Location Address
First Line	:	1229 SALEM GATE DRIVE
Second Line	:
City	:	CONYERS
State	:	GA
Zip	:	30013-1362
Country	:	US
Telephone Number	:	770-679-4503
Fax Number	:	888-273-6606

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	MRS. SELINA Y ELLIS
Credential	:
Telephone Number	:	770-679-4503

Provider Enumeration Date	:	10/26/2015
Last Update Date	:	01/11/2016

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