Provider Demographics
NPI:1255723813
Name:COTTER PERSONAL CARE HOME LLC
Entity type:Organization
Organization Name:COTTER PERSONAL CARE HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:URICK
Authorized Official - Middle Name:
Authorized Official - Last Name:LADONIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-226-4244
Mailing Address - Street 1:PO BOX 310147
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31131-0147
Mailing Address - Country:US
Mailing Address - Phone:770-226-4244
Mailing Address - Fax:
Practice Address - Street 1:5146 COTTER DR
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:GA
Practice Address - Zip Code:30291-1812
Practice Address - Country:US
Practice Address - Phone:770-226-4244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA241816320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities