Provider Demographics
NPI:1689737033
Name:HIGHLAND RIVERS CSB
Entity Type:Organization
Organization Name:HIGHLAND RIVERS CSB
Other - Org Name:HIGHLAND RIVERS POLK OP OFFICE AND CRISIS STABILIZATION PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BEARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-270-5000
Mailing Address - Street 1:1401 APPLEWOOD DRIVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2699
Mailing Address - Country:US
Mailing Address - Phone:706-270-5002
Mailing Address - Fax:706-370-7749
Practice Address - Street 1:180 WATER OAK DR
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2095
Practice Address - Country:US
Practice Address - Phone:770-748-2225
Practice Address - Fax:770-749-0939
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HIGHLAND RIVERS CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-18
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1447256243OtherORGANIZATIONAL MASTER NPI
GA000759448JMedicaid
GAGRP2111Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER