Provider Demographics
NPI:1407159585
Name:CROWN PERSONAL CARE HOME
Entity Type:Organization
Organization Name:CROWN PERSONAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-216-1618
Mailing Address - Street 1:891 STORMY LN
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-5984
Mailing Address - Country:US
Mailing Address - Phone:678-216-1618
Mailing Address - Fax:
Practice Address - Street 1:891 STORMY LN
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30238-5984
Practice Address - Country:US
Practice Address - Phone:678-216-1618
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031-01-246-1320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities