NPIMap

Organization Active NPI

Shallowford Group Home

  • Community/Behavioral Health Agency
  • Atlanta, GA
National Provider Identifier
1306981113
Registry record updated Aug 19, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Behavioral Health AgencyTaxonomy code 251S00000X
Legal business name
SHALLOWFORD GROUP HOME
Practice address
2473 Shallowford Rd NE
Atlanta, GA 30345-1363
Phone
(404) 636-0955
Fax
(404) 636-0955
NPI assigned
Feb 20, 2007
Last updated
Aug 19, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
DEKALB COMMUNITY SERVICE BOARDAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 19, 2024

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

Authorized official

Name
Fabio Bruno Van Der Merwe
Title
Coo
Phone
(404) 294-3836

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Behavioral Health Agency 251S00000X NU Primary

Addresses

Primary practice location

2473 Shallowford Rd NE
Atlanta, GA 30345-1363

Mailing address

445 Winn Way FL 4
Decatur, GA 30030-1707
Phone (404) 508-7796

Other names 1

  • Shallowford Group Home Other name

National Provider Directory

National Provider Directory
Tax ID family
Dekalb Community SVC BD24 organizations share this tax ID, including this one
Part of
Dekalb Community SVC BD

Other organizations with this tax ID 23

Organizations that report the same tax identification number in the National Provider Directory.

View all 23

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1171929600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724025600000",
    "number": "1306981113",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "445 WINN WAY FL 4",
            "city": "DECATUR",
            "state": "GA",
            "postal_code": "300301707",
            "telephone_number": "404-508-7796"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2473 SHALLOWFORD RD NE",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303451363",
            "telephone_number": "404-636-0955",
            "fax_number": "404-636-0955"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHALLOWFORD GROUP HOME",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "DEKALB COMMUNITY SERVICE BOARD",
        "enumeration_date": "2007-02-20",
        "last_updated": "2024-08-19",
        "certification_date": "2024-08-19",
        "status": "A",
        "authorized_official_last_name": "VAN DER MERWE",
        "authorized_official_first_name": "FABIO",
        "authorized_official_middle_name": "BRUNO",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "404-294-3836"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shallowford Group Home",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Atlanta, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 19, 2024; 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.