Provider Demographics
NPI:1164545539
Name:OPEN HEARTS PERSONAL CARE HOMES, LLC
Entity Type:Organization
Organization Name:OPEN HEARTS PERSONAL CARE HOMES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PRINCIPAL
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANNA
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:CLARKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-410-1669
Mailing Address - Street 1:3418 BRETON CT NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-2408
Mailing Address - Country:US
Mailing Address - Phone:770-323-3751
Mailing Address - Fax:404-551-3448
Practice Address - Street 1:4031 BELMONT RIDGE DR
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-4069
Practice Address - Country:US
Practice Address - Phone:770-981-3497
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA754258102AMedicaid