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Organization
HATTIE CLAY OLIVER PCH
Active
Organization
HATTIE CLAY OLIVER PCH
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JAMES C FORD (CEO)
(770) 575-0582
Entity
Organization
Contact information
Practice address
418 VININGS VINTAGE CIR, MABLETON, GA 30126-7208
(770) 575-0582
(404) 756-4894
Mailing address
1180 MADISON GREEN LN SW, MABLETON, GA 30126-2154
(770) 575-0582
(404) 756-4894
Taxonomy
Speciality
Code
Description
License number
State
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
Primary
PCH005570
GA
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
PCH005570
GA
Other
Enumeration date
12/02/2011
Last updated
12/06/2011
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