Provider Demographics
NPI:1306034012
Name:CLAYTON MHDDAD
Entity Type:Organization
Organization Name:CLAYTON MHDDAD
Other - Org Name:CLAYTON CSB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-478-2280
Mailing Address - Street 1:157 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-3546
Mailing Address - Country:US
Mailing Address - Phone:770-478-2280
Mailing Address - Fax:770-477-9772
Practice Address - Street 1:8132 KENDRICK RD
Practice Address - Street 2:B&C
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30238-2933
Practice Address - Country:US
Practice Address - Phone:770-471-5249
Practice Address - Fax:770-477-9772
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLAYTON MHDDAD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-09
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00604205QMedicaid
GAGRP2322Medicare PIN