Provider Demographics
NPI:1164668596
Name:CHOICES FOR LIFE OF GEORGIA, LLC
Entity Type:Organization
Organization Name:CHOICES FOR LIFE OF GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:FELLRATH
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:405-751-0800
Mailing Address - Street 1:4330 GILBERT AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-6519
Mailing Address - Country:US
Mailing Address - Phone:770-338-0800
Mailing Address - Fax:770-338-2219
Practice Address - Street 1:4330 GILBERT AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6519
Practice Address - Country:US
Practice Address - Phone:770-338-0800
Practice Address - Fax:770-338-2219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACPFC001072251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA001462443AMedicaid