Provider Demographics
NPI:1811385966
Name:DISTINCTIVE PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:DISTINCTIVE PROFESSIONAL SERVICES
Other - Org Name:DPS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATRICE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-905-0423
Mailing Address - Street 1:8343 ROSWELL RD
Mailing Address - Street 2:443
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350-2810
Mailing Address - Country:US
Mailing Address - Phone:800-863-9003
Mailing Address - Fax:
Practice Address - Street 1:8343 ROSWELL RD
Practice Address - Street 2:443
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30350-2810
Practice Address - Country:US
Practice Address - Phone:800-863-9003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home