Provider Demographics
NPI:1942374350
Name:SOUTH GEORGIA CSB
Entity Type:Organization
Organization Name:SOUTH GEORGIA CSB
Other - Org Name:COOK DD SERVICES
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:229-671-6101
Mailing Address - Street 1:203 INDUSTRIAL PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:GA
Mailing Address - Zip Code:31620
Mailing Address - Country:US
Mailing Address - Phone:229-896-7994
Mailing Address - Fax:229-896-3709
Practice Address - Street 1:203 INDUSTRIAL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:GA
Practice Address - Zip Code:31620
Practice Address - Country:US
Practice Address - Phone:229-896-7994
Practice Address - Fax:229-896-3709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000607032AMedicaid
GA000607032WMedicaid