1710573936 NPI number — EAST CONYERS BEHAVIORAL HEALTH CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710573936 NPI number — EAST CONYERS BEHAVIORAL HEALTH CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST CONYERS BEHAVIORAL HEALTH CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710573936
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1277 WELLBROOK CIR NE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONYERS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30012-3973
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-679-5453
Provider Business Mailing Address Fax Number:
770-679-5457

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1277 WELLBROOK CIR NE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONYERS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30012-3973
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-679-5453
Provider Business Practice Location Address Fax Number:
770-679-5457
Provider Enumeration Date:
12/13/2020

Additional Information

Authorized Official

Authorized Official Last Name:
YALLAH
Authorized Official First Name:
SELMA
Authorized Official Middle Name:
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
770-679-5453

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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