Provider Demographics
NPI:1780853168
Name:MCINTOSH TRAIL COMMUNITY SERVICE BOARD
Entity Type:Organization
Organization Name:MCINTOSH TRAIL COMMUNITY SERVICE BOARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOLLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-358-8251
Mailing Address - Street 1:1501A KALAMAZOO DR
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-3919
Mailing Address - Country:US
Mailing Address - Phone:770-358-8250
Mailing Address - Fax:770-229-3223
Practice Address - Street 1:180 WATSON STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-1536
Practice Address - Country:US
Practice Address - Phone:770-229-3125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health