Provider Demographics
NPI:1639473077
Name:FAITH HEALTH SERVICES OF GA.
Entity Type:Organization
Organization Name:FAITH HEALTH SERVICES OF GA.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:HERMA
Authorized Official - Last Name:VICKERIE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:770-598-8031
Mailing Address - Street 1:240 PROSPECT PL
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-5454
Mailing Address - Country:US
Mailing Address - Phone:678-624-1646
Mailing Address - Fax:770-442-3320
Practice Address - Street 1:240 PROSPECT PL
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-5454
Practice Address - Country:US
Practice Address - Phone:678-624-1646
Practice Address - Fax:770-442-3320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000696935GMedicaid
GA703485909AMedicaid