Provider Demographics
NPI:1174868707
Name:HOUSEHOLD OF FAITH
Entity type:Organization
Organization Name:HOUSEHOLD OF FAITH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXCUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-774-8033
Mailing Address - Street 1:341 OLD GRIFFIN RD
Mailing Address - Street 2:P.O BOX1804
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-4952
Mailing Address - Country:US
Mailing Address - Phone:678-774-8033
Mailing Address - Fax:
Practice Address - Street 1:341 OLD GRIFFIN RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-4952
Practice Address - Country:US
Practice Address - Phone:678-774-8033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOUSEHOLD OF FAITH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-07
Last Update Date:2012-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA320900000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities