Provider Demographics
NPI:1164995965
Name:COMMUNITY SERVICE BOARD OF EAST CENTRAL GEORGIA
Entity Type:Organization
Organization Name:COMMUNITY SERVICE BOARD OF EAST CENTRAL GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-432-4837
Mailing Address - Street 1:3421 MIKE PADGETT HWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-3815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1908 DRIFTWOOD DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-4113
Practice Address - Country:US
Practice Address - Phone:706-432-4837
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY SERVICE BOARD OF EAST CENTRAL GEORGIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities