Provider Demographics
NPI:1316285315
Name:LIZZY'S ADULT COMMUNITY SERVICE CENTER
Entity type:Organization
Organization Name:LIZZY'S ADULT COMMUNITY SERVICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:706-533-0218
Mailing Address - Street 1:1514 BALDWIN LAKES DR
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-5887
Mailing Address - Country:US
Mailing Address - Phone:706-533-0218
Mailing Address - Fax:706-869-2015
Practice Address - Street 1:1514 BALDWIN LAKES DR
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-5887
Practice Address - Country:US
Practice Address - Phone:706-533-0218
Practice Address - Fax:706-869-2015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA366878280BMedicaid
GA366878280AMedicaid