Provider Demographics
NPI:1598024440
Name:BEACON HEALTH SYSTEMS, INC.
Entity Type:Organization
Organization Name:BEACON HEALTH SYSTEMS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PRINCE
Authorized Official - Middle Name:
Authorized Official - Last Name:EJEMOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-457-7706
Mailing Address - Street 1:3898 CRAGGY PERCH
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-8700
Mailing Address - Country:US
Mailing Address - Phone:478-845-0881
Mailing Address - Fax:478-845-0858
Practice Address - Street 1:507 N HOUSTON RD
Practice Address - Street 2:SUITE D-3
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-8828
Practice Address - Country:US
Practice Address - Phone:478-845-0881
Practice Address - Fax:478-845-0858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-14
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005-R-1041253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care