Provider Demographics
NPI: | 1851811210 |
---|---|
Name: | COMMUNITY SERVICE BOARD OF MIDDLE GEORGIA |
Entity Type: | Organization |
Organization Name: | COMMUNITY SERVICE BOARD OF MIDDLE GEORGIA |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CFO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KEITH |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | MORAN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 478-275-6811 |
Mailing Address - Street 1: | 223 N ANDERSON DR |
Mailing Address - Street 2: | |
Mailing Address - City: | SWAINSBORO |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30401-4440 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 478-289-2683 |
Mailing Address - Fax: | 478-289-2798 |
Practice Address - Street 1: | 1114 CLARKS MILL RD |
Practice Address - Street 2: | |
Practice Address - City: | LOUISVILLE |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30434-5304 |
Practice Address - Country: | US |
Practice Address - Phone: | 478-625-7214 |
Practice Address - Fax: | 478-625-7240 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-06-26 |
Last Update Date: | 2017-06-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251S00000X | Agencies | Community/Behavioral Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
GA | 000709288F | Medicaid |