Provider Demographics
NPI:1194026807
Name:CONEBLAA FAMILY FOUNDATION CORP
Entity Type:Organization
Organization Name:CONEBLAA FAMILY FOUNDATION CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:PASTOR
Authorized Official - Phone:478-254-2878
Mailing Address - Street 1:1950 PINE HILL DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-4434
Mailing Address - Country:US
Mailing Address - Phone:478-254-2878
Mailing Address - Fax:
Practice Address - Street 1:1950 PINE HILL DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-4434
Practice Address - Country:US
Practice Address - Phone:478-254-2878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty