Provider Demographics
NPI:1306178546
Name:GEORGIA MOUNTAIN COMMUNITY SERVICES
Entity Type:Organization
Organization Name:GEORGIA MOUNTAIN COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:B
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-513-5762
Mailing Address - Street 1:4331 THURMON TANNER RD
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-2829
Mailing Address - Country:US
Mailing Address - Phone:678-513-5762
Mailing Address - Fax:
Practice Address - Street 1:4331 THURMON TANNER RD
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-2829
Practice Address - Country:US
Practice Address - Phone:678-513-5762
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-12
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000607054BJMedicaid
GA000607054AYMedicaid