Provider Demographics
NPI:1851626733
Name:ULTIMATE LIVING SERVICE, INC
Entity Type:Organization
Organization Name:ULTIMATE LIVING SERVICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:404-401-1094
Mailing Address - Street 1:1516 CROOKED TREE CIR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-3723
Mailing Address - Country:US
Mailing Address - Phone:404-401-1094
Mailing Address - Fax:
Practice Address - Street 1:1516 CROOKED TREE CIR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30088-3723
Practice Address - Country:US
Practice Address - Phone:404-401-1094
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044017288320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities