Provider Demographics
NPI:1588026140
Name:CLAYTON CENTER CSB
Entity Type:Organization
Organization Name:CLAYTON CENTER CSB
Other - Org Name:PAULA CRANE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:REVENUE UTILIZATION MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LOQUETA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGHEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-478-2280
Mailing Address - Street 1:1792 MOUNT ZION RD
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-4114
Mailing Address - Country:US
Mailing Address - Phone:770-960-2009
Mailing Address - Fax:770-960-2024
Practice Address - Street 1:157 SMITH ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-3546
Practice Address - Country:US
Practice Address - Phone:770-478-2280
Practice Address - Fax:770-477-9772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2322OtherMEDICARE
GAGRP2322OtherMEDICARE