Provider Demographics
NPI:1922353234
Name:GAINESVILLE JAYCEES VOCATIONAL REHAB CENTER, INC.
Entity Type:Organization
Organization Name:GAINESVILLE JAYCEES VOCATIONAL REHAB CENTER, INC.
Other - Org Name:REHABILITATION INDUSTRIES OF N.E. GA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:770-535-7464
Mailing Address - Street 1:PO BOX 907413
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-0907
Mailing Address - Country:US
Mailing Address - Phone:770-535-7464
Mailing Address - Fax:770-531-5697
Practice Address - Street 1:930 ATHENS ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-6937
Practice Address - Country:US
Practice Address - Phone:770-535-7464
Practice Address - Fax:770-531-5697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000800456AMedicaid