1033506712 NPI number — ST. MARY'S INDEPENDENT LIVING EXTENSIONS

Table of content: (NPI 1033506712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033506712 NPI number — ST. MARY'S INDEPENDENT LIVING EXTENSIONS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. MARY'S INDEPENDENT LIVING EXTENSIONS
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:
1033506712
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 GLOSTER RD NW STE 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWRENCEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30044-4479
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-279-5115
Provider Business Mailing Address Fax Number:
770-923-2059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 GLOSTER RD NW STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30044-4479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-279-5115
Provider Business Practice Location Address Fax Number:
770-923-2059
Provider Enumeration Date:
04/21/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PIEPER
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
770-279-5115

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , with the licence number:  067-R-0388 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 779876528B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 779876528A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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