Provider Demographics
NPI:1710683396
Name:WILLIE B GARDNER ASSISTED LIVING INC.
Entity Type:Organization
Organization Name:WILLIE B GARDNER ASSISTED LIVING INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHAURINA
Authorized Official - Middle Name:S
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-663-9674
Mailing Address - Street 1:1262 KING RD
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-2952
Mailing Address - Country:US
Mailing Address - Phone:678-789-5174
Mailing Address - Fax:
Practice Address - Street 1:1262 KING RD
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-2952
Practice Address - Country:US
Practice Address - Phone:678-789-5174
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility