Provider Demographics
NPI:1578893228
Name:LOOKOUT MOUNTAIN COMMUNITY SERVICE
Entity Type:Organization
Organization Name:LOOKOUT MOUNTAIN COMMUNITY SERVICE
Other - Org Name:HOST HOME-LAURA DOTSON
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-638-5580
Mailing Address - Street 1:PO BOX 1027
Mailing Address - Street 2:
Mailing Address - City:LA FAYETTE
Mailing Address - State:GA
Mailing Address - Zip Code:30728-1027
Mailing Address - Country:US
Mailing Address - Phone:706-638-5580
Mailing Address - Fax:706-638-5445
Practice Address - Street 1:2442 BACK VALLEY RD
Practice Address - Street 2:
Practice Address - City:LYERLY
Practice Address - State:GA
Practice Address - Zip Code:30730-5030
Practice Address - Country:US
Practice Address - Phone:706-638-5580
Practice Address - Fax:706-638-5445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-31
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000604513DLMedicaid