Provider Demographics
NPI:1629207733
Name:SOUTHERN INTERNATIONAL LIVING, INC
Entity Type:Organization
Organization Name:SOUTHERN INTERNATIONAL LIVING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MINNIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:404-684-6884
Mailing Address - Street 1:3437 MOUNT OLIVE RD
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-5812
Mailing Address - Country:US
Mailing Address - Phone:404-684-6884
Mailing Address - Fax:404-551-3549
Practice Address - Street 1:3437 MOUNT OLIVE RD
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-5812
Practice Address - Country:US
Practice Address - Phone:404-547-1291
Practice Address - Fax:404-551-3549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-09
Last Update Date:2012-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACLA001010320900000X
GACLA000974320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA181308327AMedicaid