Provider Demographics
NPI:1659707206
Name:JUSTIN HEALTH SYSTEMS, INC
Entity Type:Organization
Organization Name:JUSTIN HEALTH SYSTEMS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENCY ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANSELM
Authorized Official - Middle Name:
Authorized Official - Last Name:UGONNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-349-6441
Mailing Address - Street 1:5859 ABERCORN ST
Mailing Address - Street 2:BLDG 2, UNIT 5
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5859 ABERCORN ST
Practice Address - Street 2:BLDG 2, UNIT 5
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5500
Practice Address - Country:US
Practice Address - Phone:912-349-6441
Practice Address - Fax:912-349-6482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-15
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025-R-0956251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003132157AMedicaid