Provider Demographics
NPI:1790385862
Name:HICKORY LOG VOCATIONAL SCHOOL INC
Entity Type:Organization
Organization Name:HICKORY LOG VOCATIONAL SCHOOL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:REV,DR
Authorized Official - Phone:770-382-6655
Mailing Address - Street 1:3680 HIGHWAY 411 NE # PO300
Mailing Address - Street 2:
Mailing Address - City:WHITE
Mailing Address - State:GA
Mailing Address - Zip Code:30184-2427
Mailing Address - Country:US
Mailing Address - Phone:770-382-6655
Mailing Address - Fax:
Practice Address - Street 1:3680 HIGHWAY 411 NE
Practice Address - Street 2:
Practice Address - City:WHITE
Practice Address - State:GA
Practice Address - Zip Code:30184-2427
Practice Address - Country:US
Practice Address - Phone:770-382-6655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities