Provider Demographics
NPI:1720395270
Name:SERVING ONE OF US
Entity Type:Organization
Organization Name:SERVING ONE OF US
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:WALKER
Authorized Official - Last Name:WORTHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-428-2749
Mailing Address - Street 1:1544 WELLBORN RD
Mailing Address - Street 2:#3
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-5492
Mailing Address - Country:US
Mailing Address - Phone:404-428-2749
Mailing Address - Fax:770-786-0499
Practice Address - Street 1:1544 WELLBORN RD
Practice Address - Street 2:#3
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-5492
Practice Address - Country:US
Practice Address - Phone:404-428-2749
Practice Address - Fax:770-786-0499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-04
Last Update Date:2010-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA600242281A251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA600242281AMedicaid