Provider Demographics
NPI:1073996245
Name:CSB CLUBHOUSE
Entity Type:Organization
Organization Name:CSB CLUBHOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:K
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-272-1190
Mailing Address - Street 1:1008 HILLCREST PKWY
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-4262
Mailing Address - Country:US
Mailing Address - Phone:478-272-1190
Mailing Address - Fax:478-274-7628
Practice Address - Street 1:1008 HILLCREST PKWY
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-4262
Practice Address - Country:US
Practice Address - Phone:478-272-1190
Practice Address - Fax:478-274-7628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300030912AMedicaid
GA300030912AMedicaid