Provider Demographics
NPI:1467108035
Name:QILLAWASI LLC
Entity Type:Organization
Organization Name:QILLAWASI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDRES
Authorized Official - Middle Name:
Authorized Official - Last Name:DARGENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-658-9610
Mailing Address - Street 1:2440 CIRCLEWOOD RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-1950
Mailing Address - Country:US
Mailing Address - Phone:470-658-9610
Mailing Address - Fax:
Practice Address - Street 1:2043 WEEMS RD.
Practice Address - Street 2:SUITE C2043
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084
Practice Address - Country:US
Practice Address - Phone:470-658-9610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational MedicineGroup - Multi-Specialty