Provider Demographics
NPI:1861680696
Name:WIDE RANGE OF RESOURCES,IINC.
Entity Type:Organization
Organization Name:WIDE RANGE OF RESOURCES,IINC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:FREZALIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:478-451-3112
Mailing Address - Street 1:1776 N JEFFERSON ST NE STE B
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-2292
Mailing Address - Country:US
Mailing Address - Phone:478-451-3112
Mailing Address - Fax:478-451-0626
Practice Address - Street 1:1776 N JEFFERSON ST NE STE B
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2292
Practice Address - Country:US
Practice Address - Phone:478-451-3112
Practice Address - Fax:478-451-0626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW000658261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA139858482AMedicaid
GA139858482BMedicaid
GAGRP7368OtherGROUP PIN
GA139858482AMedicaid
GA80BBGLVMedicare PIN