Provider Demographics
NPI:1740535830
Name:COMMUNITY CLINICAL SERVICES LLC
Entity type:Organization
Organization Name:COMMUNITY CLINICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VERWAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-524-2195
Mailing Address - Street 1:882 MARTIN LUTHER KING JR DR SW STE B
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30314-3606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:866-502-0926
Practice Address - Street 1:8401 UNIVERSITY EXEC PARK DR
Practice Address - Street 2:SUITE 127
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3386
Practice Address - Country:US
Practice Address - Phone:404-838-1550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health