Provider Demographics
NPI:1215592431
Name:EGO IDEAL, INC.
Entity Type:Organization
Organization Name:EGO IDEAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-705-9527
Mailing Address - Street 1:3574 COLUMBIA PKWY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-3349
Mailing Address - Country:US
Mailing Address - Phone:678-705-9527
Mailing Address - Fax:
Practice Address - Street 1:4484 COVINGTON HWY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-1203
Practice Address - Country:US
Practice Address - Phone:678-705-9527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No305S00000XManaged Care OrganizationsPoint of Service