Provider Demographics
NPI:1558657494
Name:EXQUISITE TRADITIONS
Entity Type:Organization
Organization Name:EXQUISITE TRADITIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLIF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-525-9500
Mailing Address - Street 1:2045 MOUNT ZION RD
Mailing Address - Street 2:SUITE 397
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-3313
Mailing Address - Country:US
Mailing Address - Phone:404-525-9500
Mailing Address - Fax:404-393-9436
Practice Address - Street 1:7265 MOUNT ZION BLVD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2519
Practice Address - Country:US
Practice Address - Phone:404-525-9500
Practice Address - Fax:404-393-9436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCH001261320700000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities