Provider Demographics
NPI:1639478688
Name:GRN: COMMUNITY SERVICE BOARDS
Entity Type:Organization
Organization Name:GRN: COMMUNITY SERVICE BOARDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SSTSR
Authorized Official - Prefix:MS
Authorized Official - First Name:ADELENE
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-784-0076
Mailing Address - Street 1:101 KIRKLAND RD
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-3317
Mailing Address - Country:US
Mailing Address - Phone:770-784-0076
Mailing Address - Fax:770-784-3036
Practice Address - Street 1:101 KIRKLAND RD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-3317
Practice Address - Country:US
Practice Address - Phone:770-784-0076
Practice Address - Fax:770-784-3036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health