Provider Demographics
NPI:1346473246
Name:THE HOMEPLACE SHELTER INC.
Entity Type:Organization
Organization Name:THE HOMEPLACE SHELTER INC.
Other - Org Name:MILDRED'S HOMEPLACE III
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-228-1985
Mailing Address - Street 1:612 E CLAY ST
Mailing Address - Street 2:610 EAST CLAY STREET
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-4608
Mailing Address - Country:US
Mailing Address - Phone:229-551-0695
Mailing Address - Fax:229-551-0694
Practice Address - Street 1:612 E CLAY ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-4608
Practice Address - Country:US
Practice Address - Phone:229-551-0695
Practice Address - Fax:229-551-0694
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE HOMEPLACE SHELTER INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-26
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA136-01-096-1251C00000X, 320900000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA136-01-096-1OtherPERSONAL CARE HOME