Provider Demographics
NPI:1649584939
Name:THE DREAM HOUSE FOR MEDICALLY FRAGILE CHILDREN, INC.
Entity Type:Organization
Organization Name:THE DREAM HOUSE FOR MEDICALLY FRAGILE CHILDREN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PROGRAM OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-717-7410
Mailing Address - Street 1:2092 SCENIC HWY N
Mailing Address - Street 2:SUITE B
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6188
Mailing Address - Country:US
Mailing Address - Phone:770-717-7410
Mailing Address - Fax:770-923-0659
Practice Address - Street 1:4896 MILLER RD SW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-5333
Practice Address - Country:US
Practice Address - Phone:770-806-1621
Practice Address - Fax:678-990-9812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACTCC001001251B00000X, 251J00000X, 253J00000X, 3140N1450X, 343900000X, 385HR2065X
GA067R0725251B00000X, 251E00000X, 251J00000X, 3140N1450X, 343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No253J00000XAgenciesFoster Care Agency
No3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
No343800000XTransportation ServicesSecured Medical Transport (VAN)
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA513959537AOtherGEORGIA MEDICAID/PEACH CARE FOR KIDS