Provider Demographics
NPI:1760609895
Name:CASSANDRA GILLIAM
Entity Type:Organization
Organization Name:CASSANDRA GILLIAM
Other - Org Name:NONE
Other - Org Type:Other Name
Authorized Official - Title/Position:RN
Authorized Official - Prefix:MS
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:SHEA
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:404-294-0499
Mailing Address - Street 1:3850 EDEN GLEN DR SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-5813
Mailing Address - Country:US
Mailing Address - Phone:770-679-4366
Mailing Address - Fax:
Practice Address - Street 1:450 WINN WAY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1715
Practice Address - Country:US
Practice Address - Phone:404-294-0499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN171251310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness