Provider Demographics
NPI:1457454514
Name:RIVER EDGE BEHAVIORAL HEALTH CENTER
Entity Type:Organization
Organization Name:RIVER EDGE BEHAVIORAL HEALTH CENTER
Other - Org Name:RIVER EDGE BEHAVIORAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHCY DIRECTOR/PIC
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:478-803-7650
Mailing Address - Street 1:175 EMERY HWY
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-3692
Mailing Address - Country:US
Mailing Address - Phone:478-803-7696
Mailing Address - Fax:478-746-5864
Practice Address - Street 1:175 EMERY HWY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3692
Practice Address - Country:US
Practice Address - Phone:478-803-7696
Practice Address - Fax:478-746-5864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
GAPHRE0055433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2019177OtherPK
GA000604986AMedicaid