Provider Demographics
NPI:1760827190
Name:DISTINCTIVELY YOURS OF GEORGIA, INC
Entity Type:Organization
Organization Name:DISTINCTIVELY YOURS OF GEORGIA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:N
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-507-0125
Mailing Address - Street 1:8435 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-3132
Mailing Address - Country:US
Mailing Address - Phone:678-479-9462
Mailing Address - Fax:770-507-9075
Practice Address - Street 1:8435 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30238-3132
Practice Address - Country:US
Practice Address - Phone:770-507-0125
Practice Address - Fax:770-507-9075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-29
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003108953BMedicaid
GA003108953EMedicaid
GA003108953DMedicaid