Provider Demographics
NPI:1245739879
Name:GEORGIA PINES COMMUNITY SERVICE BOARD
Entity Type:Organization
Organization Name:GEORGIA PINES COMMUNITY SERVICE BOARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLERICAL SUPPORT
Authorized Official - Prefix:
Authorized Official - First Name:JONAS
Authorized Official - Middle Name:
Authorized Official - Last Name:NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-225-5031
Mailing Address - Street 1:1102 SMITH AVE STE K
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5740
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:407 CLOVERDALE DRIVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792
Practice Address - Country:US
Practice Address - Phone:229-233-8904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000754795HMedicaid