Provider Demographics
NPI:1851600324
Name:AVONDALE HEALTH SERVICES INC.
Entity Type:Organization
Organization Name:AVONDALE HEALTH SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:WALDEMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:404-294-0203
Mailing Address - Street 1:3508 KENSINGTON RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-1328
Mailing Address - Country:US
Mailing Address - Phone:404-294-0203
Mailing Address - Fax:404-294-0208
Practice Address - Street 1:3508 KENSINGTON RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-1328
Practice Address - Country:US
Practice Address - Phone:404-294-0203
Practice Address - Fax:404-294-0208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00483931A310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300028513AMedicaid
GA300028513BMedicaid