Provider Demographics
NPI:1528574431
Name:HOUSE OF CONCRETE ROSES, LLC
Entity Type:Organization
Organization Name:HOUSE OF CONCRETE ROSES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TANEQUA
Authorized Official - Middle Name:
Authorized Official - Last Name:DORSEY
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:404-697-7360
Mailing Address - Street 1:1133 HUFF RD NW APT 766
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-4327
Mailing Address - Country:US
Mailing Address - Phone:404-697-7360
Mailing Address - Fax:
Practice Address - Street 1:1133 HUFF RD NW APT 766
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-4327
Practice Address - Country:US
Practice Address - Phone:404-697-7360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness