Provider Demographics
NPI:1962616912
Name:INTERGENERATIONAL RESOURCE CENTER, INC.
Entity type:Organization
Organization Name:INTERGENERATIONAL RESOURCE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:EVELYN
Authorized Official - Last Name:SANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:404-524-1023
Mailing Address - Street 1:444 EDGEWOOD AVENUE, S.E.
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-1838
Mailing Address - Country:US
Mailing Address - Phone:404-524-1023
Mailing Address - Fax:404-577-1025
Practice Address - Street 1:444 EDGEWOOD AVE SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1838
Practice Address - Country:US
Practice Address - Phone:404-524-1023
Practice Address - Fax:404-577-1025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000120117AMedicaid
GA000438105CMedicaid
GA000438105AMedicaid
GA000438105BMedicaid
GA000438105DMedicaid