Provider Demographics
NPI:1487822912
Name:CRISP REGIONAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:CRISP REGIONAL HOSPITAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR REV INT
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:BEARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-276-3146
Mailing Address - Street 1:910 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-3254
Mailing Address - Country:US
Mailing Address - Phone:229-271-9686
Mailing Address - Fax:229-271-9689
Practice Address - Street 1:910 N 5TH ST
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015
Practice Address - Country:US
Practice Address - Phone:229-271-9686
Practice Address - Fax:229-271-9689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040R0003251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA760967211AMedicaid