Provider Demographics
NPI:1326017062
Name:DOUGLAS COUNTY BOARD OF HEALTH
Entity Type:Organization
Organization Name:DOUGLAS COUNTY BOARD OF HEALTH
Other - Org Name:DOUGLAS COUNTY PUBLIC HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:VIRGIL
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:770-514-2300
Mailing Address - Street 1:6770 SELMAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134
Mailing Address - Country:US
Mailing Address - Phone:770-514-2300
Mailing Address - Fax:770-514-2811
Practice Address - Street 1:6770 SELMAN DRIVE
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134
Practice Address - Country:US
Practice Address - Phone:770-514-2300
Practice Address - Fax:770-514-2811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000051939BMedicaid
GA000058616GMedicaid
GA000456431FMedicaid
GA000058616DMedicaid
GA000058616GMedicaid