1023737079 NPI number — OURWAY DEMENTIA SERVICES LLC

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 1023737079 NPI number — OURWAY DEMENTIA SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OURWAY DEMENTIA SERVICES LLC
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:
1023737079
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
650 PONCE DE LEON AVE SUITE 300 #2449
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
470-726-0405
Provider Business Mailing Address Fax Number:
678-550-9941

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 WERNER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOCUST GROVE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30248-2109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-651-7254
Provider Business Practice Location Address Fax Number:
678-550-9941
Provider Enumeration Date:
08/23/2022

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
CHANTELLE
Authorized Official Middle Name:
JOHNSON
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
678-651-7254

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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