Provider Demographics
NPI:1003377086
Name:CHRIS 180, INC.
Entity Type:Organization
Organization Name:CHRIS 180, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINSITRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BELLOR
Authorized Official - Suffix:
Authorized Official - Credentials:BBA, PA, NP, AASEET
Authorized Official - Phone:404-486-9034
Mailing Address - Street 1:1017 FAYETTEVILLE RD SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-2932
Mailing Address - Country:US
Mailing Address - Phone:404-486-9034
Mailing Address - Fax:404-835-9350
Practice Address - Street 1:3700 MARTIN LUTHER KING DR SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-3674
Practice Address - Country:US
Practice Address - Phone:404-486-9034
Practice Address - Fax:404-835-9350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-30
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300023628AMedicaid
GA640804505KMedicaid