Provider Demographics
NPI: | 1164846499 |
---|---|
Name: | 3DK INC-GEORGIA |
Entity Type: | Organization |
Organization Name: | 3DK INC-GEORGIA |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DERRICK |
Authorized Official - Middle Name: | E |
Authorized Official - Last Name: | KIMBLE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MED |
Authorized Official - Phone: | 706-495-2351 |
Mailing Address - Street 1: | 2903 GALAHAD WAY |
Mailing Address - Street 2: | |
Mailing Address - City: | AUGUSTA |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30909-9147 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 706-495-2351 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2903 GALAHAD |
Practice Address - Street 2: | |
Practice Address - City: | AUGUSTA |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30909 |
Practice Address - Country: | US |
Practice Address - Phone: | 706-495-2351 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2014-02-06 |
Last Update Date: | 2014-02-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 251S00000X | Agencies | Community/Behavioral Health | ||
No | 103K00000X | Behavioral Health & Social Service Providers | Behavior Analyst | Group - Single Specialty | |
No | 251E00000X | Agencies | Home Health | Group - Single Specialty |