Provider Demographics
NPI:1972192144
Name:GEORGIA IMMUNIZATION CENTER & COMMUNITY SERVICES INC
Entity Type:Organization
Organization Name:GEORGIA IMMUNIZATION CENTER & COMMUNITY SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-907-9571
Mailing Address - Street 1:6721 SPRINGDALE DR STE A
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2455
Mailing Address - Country:US
Mailing Address - Phone:770-907-9571
Mailing Address - Fax:
Practice Address - Street 1:6721 SPRINGDALE DR STE A
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2455
Practice Address - Country:US
Practice Address - Phone:770-907-9571
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health