Organization
SHIRLEY HOME AWAY FROM HOME
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SHIRLEY WILSON (ADMINISTOR)
(678) 557-2207
Entity
Organization
Contact information
Practice address
8412 RED CEDAR WAY, RIVERDALE, GA 30274-4562
(678) 557-2207
Mailing address
8412 RED CEDAR WAY, RIVERDALE, GA 30274-4562
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
155482054A
—
GA
Enumeration date
09/09/2009
Last updated
09/09/2009
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