Provider Demographics
NPI:1700022571
Name:THE FAMILY CENTER OF SOUTH DEKALB, LLC
Entity Type:Organization
Organization Name:THE FAMILY CENTER OF SOUTH DEKALB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MIA
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:BSW, MS, MBA
Authorized Official - Phone:770-875-5504
Mailing Address - Street 1:5000 SNAPFINGER WOODS DR
Mailing Address - Street 2:SUITE C-100
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-4085
Mailing Address - Country:US
Mailing Address - Phone:678-418-0890
Mailing Address - Fax:678-418-0892
Practice Address - Street 1:5000 SNAPFINGER WOODS DR
Practice Address - Street 2:SUITE C-100
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-4085
Practice Address - Country:US
Practice Address - Phone:678-418-0890
Practice Address - Fax:678-418-0892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-29
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA967590362AMedicaid