Provider Demographics
NPI:1609064450
Name:CLAYTON MHDDAD
Entity Type:Organization
Organization Name:CLAYTON MHDDAD
Other - Org Name:CLAYTON CSB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXCUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JADE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-478-2280
Mailing Address - Street 1:112 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-3563
Mailing Address - Country:US
Mailing Address - Phone:770-478-2280
Mailing Address - Fax:770-477-9772
Practice Address - Street 1:9307 FOREST KNOLL DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30238-5701
Practice Address - Country:US
Practice Address - Phone:770-473-6124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLAYTON MHDDAD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00606922CMedicaid
GAGRP2322Medicare PIN