Provider Demographics
NPI:1366075848
Name:LIAGIBA, INC
Entity type:Organization
Organization Name:LIAGIBA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:770-365-6820
Mailing Address - Street 1:518 LAKE MICHELE CT
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-1401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:678-528-3017
Practice Address - Street 1:518 LAKE MICHELE CT
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30088-1401
Practice Address - Country:US
Practice Address - Phone:770-365-6820
Practice Address - Fax:678-528-3017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA845251295BMedicaid