Provider Demographics
NPI:1871667675
Name:SOUTH GEORGIA CSB
Entity Type:Organization
Organization Name:SOUTH GEORGIA CSB
Other - Org Name:PROJECT LIGHT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-245-2379
Mailing Address - Street 1:1108 S PATTERSON ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-6348
Mailing Address - Country:US
Mailing Address - Phone:229-245-6410
Mailing Address - Fax:229-293-6242
Practice Address - Street 1:1108 S PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-6348
Practice Address - Country:US
Practice Address - Phone:229-245-6410
Practice Address - Fax:229-293-6242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2255Medicare ID - Type Unspecified