Provider Demographics
NPI:1760714299
Name:SPECTRUM HABILITATION SERVICE INC.
Entity Type:Organization
Organization Name:SPECTRUM HABILITATION SERVICE INC.
Other - Org Name:SPECTRUM HABILITATION SERVICES #A, #B, #C, #D, #E
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-276-2222
Mailing Address - Street 1:310 MAGNOLIA WALK LN
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-4072
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:404-691-4354
Practice Address - Street 1:310 MAGNOLIA WALK LANE
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349
Practice Address - Country:US
Practice Address - Phone:404-276-2222
Practice Address - Fax:404-691-4354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA252549320BMedicaid