Provider Demographics
NPI:1992058739
Name:DIAMONDS IN THE ROUGH SERVICES FOR YOUTH AND FAMILIES INC.
Entity type:Organization
Organization Name:DIAMONDS IN THE ROUGH SERVICES FOR YOUTH AND FAMILIES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KHRYSTAL
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:BSW MA
Authorized Official - Phone:404-353-4152
Mailing Address - Street 1:1741 BROAD RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-9160
Mailing Address - Country:US
Mailing Address - Phone:404-353-4152
Mailing Address - Fax:
Practice Address - Street 1:2426 WOOD VALLEY DR
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-1457
Practice Address - Country:US
Practice Address - Phone:404-608-1536
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA397016252AMedicaid