Provider Demographics
NPI:1093963944
Name:SOUTH GEORGIA TREATMENT, INC
Entity Type:Organization
Organization Name:SOUTH GEORGIA TREATMENT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:MCCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-775-9044
Mailing Address - Street 1:794 MCDONOUGH RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-1572
Mailing Address - Country:US
Mailing Address - Phone:770-775-9044
Mailing Address - Fax:
Practice Address - Street 1:794 MCDONOUGH RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-1572
Practice Address - Country:US
Practice Address - Phone:770-775-9044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANTP-001027261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone