Provider Demographics
NPI:1023550407
Name:AMELIA GARDENS INC
Entity Type:Organization
Organization Name:AMELIA GARDENS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ISOKEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ONAIWU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-712-4903
Mailing Address - Street 1:576 NICKAJACK RD SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-1419
Mailing Address - Country:US
Mailing Address - Phone:770-712-4903
Mailing Address - Fax:
Practice Address - Street 1:576 NICKAJACK RD SW
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-1419
Practice Address - Country:US
Practice Address - Phone:770-712-4903
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033-02-028-1310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003168137AMedicaid