Organization
NEW DOMUS PERSONAL CARE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JACKIE OTHELLA SMITH JR. (CEO)
(770) 996-6588
Entity
Organization
Contact information
Practice address
2650 COLONIAL DR, COLLEGE PARK, GA 30337-4923
(404) 209-9296
Mailing address
6229 JOHNSON RD, RIVERDALE, GA 30274-1806
(770) 996-6588
(770) 997-8240
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
060-01-256-2
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
112615323A
—
GA
Enumeration date
07/04/2007
Last updated
08/26/2016
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