Provider Demographics
NPI:1932487691
Name:AUGUSTA DEVELOPMENTAL SPECIALISTS, LLC
Entity Type:Organization
Organization Name:AUGUSTA DEVELOPMENTAL SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:VERNELL
Authorized Official - Last Name:DONALDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-396-0604
Mailing Address - Street 1:1303 D'ANTIGNAC STREET
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901
Mailing Address - Country:US
Mailing Address - Phone:706-396-0600
Mailing Address - Fax:706-396-0606
Practice Address - Street 1:1303 D'ANTIGNAC STREET
Practice Address - Street 2:SUITE 2100
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901
Practice Address - Country:US
Practice Address - Phone:706-396-0600
Practice Address - Fax:706-396-0606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-29
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0441842080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003115063AMedicaid