1992058739 NPI number — DIAMONDS IN THE ROUGH SERVICES FOR YOUTH AND FAMILIES INC.

Table of content: (NPI 1992058739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992058739 NPI number — DIAMONDS IN THE ROUGH SERVICES FOR YOUTH AND FAMILIES INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIAMONDS IN THE ROUGH SERVICES FOR YOUTH AND FAMILIES 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:
1992058739
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1741 BROAD RIVER RD
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:
30349-9160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-353-4152
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2426 WOOD VALLEY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORROW
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30260-1457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-608-1536
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
KHRYSTAL
Authorized Official Middle Name:
JOY
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
404-353-4152

Provider Taxonomy Codes

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

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

  • Identifier: 397016252A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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