Provider Demographics
NPI:1720318843
Name:ALLGOOD MANOR ASSISTANT HOME INC.
Entity Type:Organization
Organization Name:ALLGOOD MANOR ASSISTANT HOME INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SOPHIA
Authorized Official - Middle Name:ANNMARIE
Authorized Official - Last Name:DRUMMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-526-9201
Mailing Address - Street 1:6358 DESHONG DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-6123
Mailing Address - Country:US
Mailing Address - Phone:678-526-9201
Mailing Address - Fax:
Practice Address - Street 1:6358 DESHONG DR
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-6123
Practice Address - Country:US
Practice Address - Phone:678-526-9201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044-01-594-1315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA129286824AOtherMEDICAID PROVIDER NUMBER