Provider Demographics
NPI:1134564131
Name:PANOLA CARE, CLA
Entity type:Organization
Organization Name:PANOLA CARE, CLA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:A
Authorized Official - Last Name:TAVARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-322-6810
Mailing Address - Street 1:3169 PEQUEA DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-1119
Mailing Address - Country:US
Mailing Address - Phone:770-322-6810
Mailing Address - Fax:
Practice Address - Street 1:3169 PEQUEA DR
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-1119
Practice Address - Country:US
Practice Address - Phone:770-322-6810
Practice Address - Fax:770-322-6810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-03
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities