Provider Demographics
NPI:1184162091
Name:FELLOWSHIP ASSISTED LIVING LLC
Entity type:Organization
Organization Name:FELLOWSHIP ASSISTED LIVING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:NAAR
Authorized Official - Suffix:
Authorized Official - Credentials:4043767658
Authorized Official - Phone:404-376-7658
Mailing Address - Street 1:277 MEDICAL WAY
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2522
Mailing Address - Country:US
Mailing Address - Phone:770-909-0221
Mailing Address - Fax:770-909-0219
Practice Address - Street 1:277 MEDICAL WAY
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2522
Practice Address - Country:US
Practice Address - Phone:770-909-0221
Practice Address - Fax:770-909-0219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031-01-241-1310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA860341286AMedicaid