Provider Demographics
NPI:1255494365
Name:HIGHLAND RIVERS CENTER, CSB
Entity Type:Organization
Organization Name:HIGHLAND RIVERS CENTER, CSB
Other - Org Name:HIGHLAND RIVERS MRWP SME SMS SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:AARON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-270-5000
Mailing Address - Street 1:1620 HICKORY ST
Mailing Address - Street 2:SUITE 406
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2312
Mailing Address - Country:US
Mailing Address - Phone:706-270-5002
Mailing Address - Fax:706-370-7749
Practice Address - Street 1:1710 WHITEHOUSE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-8523
Practice Address - Country:US
Practice Address - Phone:706-270-5050
Practice Address - Fax:706-270-5052
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HIGHLAND RIVERS CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-19
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000603468EMedicaid
GA1447256243OtherORGANIZATION MASTER NPI