Provider Demographics
NPI:1619421138
Name:SOUTH GEORGIA COMMUNITY SERVICE BOARD
Entity Type:Organization
Organization Name:SOUTH GEORGIA COMMUNITY SERVICE BOARD
Other - Org Name:BEHAVIORAL HEALTH SERVICES OF SOUTH GEORGIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAYMAL
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-671-6140
Mailing Address - Street 1:3120 N OAK STREET EXT STE C
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-5910
Mailing Address - Country:US
Mailing Address - Phone:229-671-6125
Mailing Address - Fax:229-671-6774
Practice Address - Street 1:1308 W PARK AVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2722
Practice Address - Country:US
Practice Address - Phone:229-671-6100
Practice Address - Fax:229-671-6774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2255Medicare UPIN