Provider Demographics
NPI:1114043403
Name:MITCHELL BAKER SERVICE CENTER
Entity Type:Organization
Organization Name:MITCHELL BAKER SERVICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING CLERK II
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:B
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-336-7977
Mailing Address - Street 1:65 INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:CAMILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31730-3912
Mailing Address - Country:US
Mailing Address - Phone:229-336-7977
Mailing Address - Fax:229-336-1346
Practice Address - Street 1:65 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-3912
Practice Address - Country:US
Practice Address - Phone:229-336-7977
Practice Address - Fax:229-336-1346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000649151AMedicaid