Provider Demographics
NPI:1467647875
Name:MENTAL RETARDATION WAIVER PROGRAM
Entity Type:Organization
Organization Name:MENTAL RETARDATION WAIVER PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-596-5582
Mailing Address - Street 1:2100 COMER AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-8725
Mailing Address - Country:US
Mailing Address - Phone:706-321-9606
Mailing Address - Fax:706-322-6576
Practice Address - Street 1:119 CLABORN ST.
Practice Address - Street 2:
Practice Address - City:CUTHBERT
Practice Address - State:GA
Practice Address - Zip Code:39840
Practice Address - Country:US
Practice Address - Phone:706-596-5583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities