Provider Demographics
NPI:1790782431
Name:LOOKOUT MOUNTAIN COMMUNITY SERVICES
Entity Type:Organization
Organization Name:LOOKOUT MOUNTAIN COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:706-638-5580
Mailing Address - Street 1:501 MIZE ST.
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:GA
Mailing Address - Zip Code:30728
Mailing Address - Country:US
Mailing Address - Phone:706-638-5580
Mailing Address - Fax:706-638-5445
Practice Address - Street 1:501 MIZE ST.
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728
Practice Address - Country:US
Practice Address - Phone:706-638-5580
Practice Address - Fax:706-638-5445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00604513EMedicaid
GA00604513GMedicaid
GA0604513UMedicaid
GA00604513HMedicaid
GA00604513ZMedicaid
GA00604513CMedicaid
GA00810059AMedicaid
GA00604513BMedicaid
GA00604513DMedicaid
GA00810059GMedicaid
GA00604513GMedicaid