Provider Demographics
NPI:1275863383
Name:BRYANA PERSONAL CARE HOME
Entity Type:Organization
Organization Name:BRYANA PERSONAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-454-7155
Mailing Address - Street 1:6276 FIELD GLEN RD
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-4911
Mailing Address - Country:US
Mailing Address - Phone:404-454-7155
Mailing Address - Fax:
Practice Address - Street 1:6276 FIELD GLEN RD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-4911
Practice Address - Country:US
Practice Address - Phone:404-454-7155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA921820039AOtherMEDICAID PROVIDER NUMBER