Provider Demographics
NPI:1104194307
Name:HATTIE CLAY OLIVER PCH
Entity Type:Organization
Organization Name:HATTIE CLAY OLIVER PCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-575-0582
Mailing Address - Street 1:1180 MADISON GREEN LN SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-2154
Mailing Address - Country:US
Mailing Address - Phone:770-575-0582
Mailing Address - Fax:404-756-4894
Practice Address - Street 1:418 VININGS VINTAGE CIR
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-7208
Practice Address - Country:US
Practice Address - Phone:770-575-0582
Practice Address - Fax:404-756-4894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-02
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCH005570320600000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities