Provider Demographics
NPI:1033160791
Name:HOSPITAL AUTHORITY OF VALDOSTA AND LOWNDES COUNTY GEORGIA
Entity Type:Organization
Organization Name:HOSPITAL AUTHORITY OF VALDOSTA AND LOWNDES COUNTY GEORGIA
Other - Org Name:GREENLEAF CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:S
Authorized Official - Last Name:HEMBREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-259-4160
Mailing Address - Street 1:PO BOX 0070
Mailing Address - Street 2:ATTN: PFS DEPT
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31603-0070
Mailing Address - Country:US
Mailing Address - Phone:229-247-4357
Mailing Address - Fax:229-244-6194
Practice Address - Street 1:2209 PINEVIEW DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-7316
Practice Address - Country:US
Practice Address - Phone:229-247-4357
Practice Address - Fax:229-244-6194
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOSPITAL AUTHORITY OF VALDOSTA AND LOWNDES COUNTY GEORGIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-15
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA92141261QM0850X, 261QM0855X, 273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAHOSP24OtherCAHABA
GA00001724AMedicaid
GA00001724AMedicaid