1477111334 NPI number — THE FERN CENTER FOR LIFE

Table of content: (NPI 1477111334)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477111334 NPI number — THE FERN CENTER FOR LIFE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE FERN CENTER FOR LIFE
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:
1477111334
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1624 NEWTON AVE SE
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:
30316-2116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-694-4205
Provider Business Mailing Address Fax Number:
877-759-8014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
158 MORELAND AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30316-1676
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-694-4205
Provider Business Practice Location Address Fax Number:
877-759-8014
Provider Enumeration Date:
06/04/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRANGE
Authorized Official First Name:
CHRISTINA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
404-694-4205

Provider Taxonomy Codes

  • Taxonomy code: 103TC1900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003766 . This is a "LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".