1487961942 NPI number — IRIE'S COMMUNITY DEVELOPMENT CENTER, INC

Table of content: (NPI 1487961942)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487961942 NPI number — IRIE'S COMMUNITY DEVELOPMENT CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IRIE'S COMMUNITY DEVELOPMENT CENTER, INC
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:
1487961942
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5495 OLD NATIONAL HWY STE C1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLEGE PARK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30349-3256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
470-357-2561
Provider Business Mailing Address Fax Number:
470-357-2564

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 MALL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31021-3035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-835-3215
Provider Business Practice Location Address Fax Number:
404-835-3217
Provider Enumeration Date:
09/06/2010

Additional Information

Authorized Official

Authorized Official Last Name:
TOWNS
Authorized Official First Name:
JUDY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
478-353-8500

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003143622A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003204906A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003140721A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003204906B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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