Provider Demographics
NPI:1053642686
Name:CSB OF EAST CENTRAL GA
Entity Type:Organization
Organization Name:CSB OF EAST CENTRAL GA
Other - Org Name:GRACE PCH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JESSIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-432-4858
Mailing Address - Street 1:3421 MIKE PADGETT HWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-3815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2115 ASHLEY DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-5085
Practice Address - Country:US
Practice Address - Phone:706-432-4858
Practice Address - Fax:706-432-3780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000927693AAMedicaid