Provider Demographics
NPI:1780953018
Name:DADE COMMUNITY LIVING ARRANGEMENT (CLA)
Entity type:Organization
Organization Name:DADE COMMUNITY LIVING ARRANGEMENT (CLA)
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIAN
Authorized Official - Middle Name:EVADNE
Authorized Official - Last Name:WALTERS-MOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-768-5997
Mailing Address - Street 1:1289 MACEDONIA CHURCH RD.
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30054-3651
Mailing Address - Country:US
Mailing Address - Phone:678-660-3339
Mailing Address - Fax:770-679-5670
Practice Address - Street 1:1289 MACEDONIA CHURCH RD.
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:GA
Practice Address - Zip Code:30054-3651
Practice Address - Country:US
Practice Address - Phone:678-660-3339
Practice Address - Fax:770-679-5670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10701-081-1376G00000X
GACN0028872680376K00000X
GA320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Multi-Specialty
No376G00000XNursing Service Related ProvidersNursing Home AdministratorGroup - Multi-Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty