Provider Demographics
NPI:1396144408
Name:CHARITY COMMUNITY LIVING ARRANGEMENT LLC
Entity type:Organization
Organization Name:CHARITY COMMUNITY LIVING ARRANGEMENT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CHARITY
Authorized Official - Middle Name:CHINASA
Authorized Official - Last Name:EKPERI
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:404-519-5248
Mailing Address - Street 1:2995 GARNET WAY
Mailing Address - Street 2:CHARITY COMMUNITY LIVING ARRANGEMENT
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349
Mailing Address - Country:US
Mailing Address - Phone:404-519-5248
Mailing Address - Fax:770-473-1712
Practice Address - Street 1:2995 GARNET WAY
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349
Practice Address - Country:US
Practice Address - Phone:404-519-5248
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACLA002141390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA674871532AMedicaid