Provider Demographics
NPI:1730694639
Name:SIGNATURE ACTIVITY CENTER
Entity type:Organization
Organization Name:SIGNATURE ACTIVITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:POPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-485-2527
Mailing Address - Street 1:PO BOX 80044
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30608-0044
Mailing Address - Country:US
Mailing Address - Phone:678-485-2527
Mailing Address - Fax:
Practice Address - Street 1:162 LEXINGTON HTS
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-2318
Practice Address - Country:US
Practice Address - Phone:706-224-4531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SIGNATURE CARE OF GEORGIA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA222938820EMedicaid