St. Mary's Independent Living Extensions

Primary specialty

Developmentally Disabled Services Day Training AgencyTaxonomy code 251C00000X

License

067-R-0388 Issued in GA

Legal business name

ST. MARY'S INDEPENDENT LIVING EXTENSIONS

Practice address

120 Gloster Rd NW Ste 3
Lawrenceville, GA 30044-4479

Phone

(770) 279-5115

Fax

(770) 923-2059

NPI assigned

Apr 21, 2015

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Paul Pieper

Title

Executive Director

Phone

(770) 279-5115

Specialties & licenses 1

Addresses

Other identifiers 2

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1429574400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1429574400000",
    "number": "1033506712",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "120 GLOSTER RD NW STE 3",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "300444479",
            "telephone_number": "770-279-5115",
            "fax_number": "770-923-2059"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "120 GLOSTER RD NW STE 3",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "300444479",
            "telephone_number": "770-279-5115",
            "fax_number": "770-923-2059"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. MARY'S INDEPENDENT LIVING EXTENSIONS",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-04-21",
        "last_updated": "2015-04-21",
        "status": "A",
        "authorized_official_last_name": "PIEPER",
        "authorized_official_first_name": "PAUL",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "770-279-5115"
    },
    "taxonomies": [
        {
            "code": "251C00000X",
            "taxonomy_group": "",
            "desc": "Day Training, Developmentally Disabled Services",
            "state": "GA",
            "license": "067-R-0388",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "779876528B",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "779876528A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Developmentally Disabled Services Day Training Agency in Lawrenceville, GA
• Providers in Lawrenceville, GA by specialty
• Developmentally Disabled Services Day Training Agency in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 21, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.