Provider Demographics
NPI:1487983227
Name:DERICHE AGENCY INC
Entity type:Organization
Organization Name:DERICHE AGENCY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-478-1029
Mailing Address - Street 1:3175 CHEROKEE ST NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2829
Mailing Address - Country:US
Mailing Address - Phone:678-490-3761
Mailing Address - Fax:678-601-6445
Practice Address - Street 1:3175 CHEROKEE ST NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2829
Practice Address - Country:US
Practice Address - Phone:678-490-3761
Practice Address - Fax:678-601-6445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA271472802AMedicaid