# HATTIE CLAY OLIVER PCH

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1104194307
- **Authorized official:** MR. JAMES C FORD (CEO)
- **Authorized official phone:** (770) 575-0582

## Contact information

- **Practice address:** 418 VININGS VINTAGE CIR, MABLETON, GA 30126-7208
- **Practice address phone:** (770) 575-0582
- **Practice address fax:** (404) 756-4894
- **Mailing address:** 1180 MADISON GREEN LN SW, MABLETON, GA 30126-2154
- **Mailing address phone:** (770) 575-0582
- **Mailing address fax:** (404) 756-4894

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 320600000X | Intellectual and/or Developmental Disabilities Residential Treatment Facility | PCH005570 | GA | Yes |
| 320900000X | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility | PCH005570 | GA | — |

## Other

- **Enumeration date:** 12/02/2011
- **Last updated:** 12/06/2011