Provider Demographics
NPI:1538329016
Name:FIRST BORN OUTREACH CENTER INC
Entity Type:Organization
Organization Name:FIRST BORN OUTREACH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-825-5119
Mailing Address - Street 1:PO BOX 109
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-0109
Mailing Address - Country:US
Mailing Address - Phone:478-825-5119
Mailing Address - Fax:
Practice Address - Street 1:103 LAVENDER STREET
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030
Practice Address - Country:US
Practice Address - Phone:478-825-5119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA111-01-013-B310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility