Provider Demographics
NPI:1194010843
Name:TIFT COUNTY BOARD OF HEALTH D/B/A DIVERSIFIED ENTERPRISES
Entity Type:Organization
Organization Name:TIFT COUNTY BOARD OF HEALTH D/B/A DIVERSIFIED ENTERPRISES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:WEB PORTAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:DURDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-386-3122
Mailing Address - Street 1:192 VIRGINIA AVE S
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-8074
Mailing Address - Country:US
Mailing Address - Phone:229-386-3122
Mailing Address - Fax:229-386-7156
Practice Address - Street 1:192 VIRGINIA AVE S
Practice Address - Street 2:SUITE 100
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-8074
Practice Address - Country:US
Practice Address - Phone:229-386-3122
Practice Address - Fax:229-386-7156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000609771AMMedicaid