Provider Demographics
NPI:1992100705
Name:CLAIRE CUSTOM CARE
Entity type:Organization
Organization Name:CLAIRE CUSTOM CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGEUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-233-8285
Mailing Address - Street 1:1452 TETHER LN
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-9210
Mailing Address - Country:US
Mailing Address - Phone:678-233-8285
Mailing Address - Fax:844-273-5942
Practice Address - Street 1:1452 TETHER LN
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-9210
Practice Address - Country:US
Practice Address - Phone:678-233-8285
Practice Address - Fax:844-273-5942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities