Provider Demographics
NPI:1972670420
Name:GEORGIA DEPARTMENT OF HUMAN RESOURCES
Entity Type:Organization
Organization Name:GEORGIA DEPARTMENT OF HUMAN RESOURCES
Other - Org Name:GRACEWOOD COMMUNITY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL HOSPITAL ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:C
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-790-2030
Mailing Address - Street 1:100 MYRTLE BLVD
Mailing Address - Street 2:
Mailing Address - City:GRACEWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30812-1500
Mailing Address - Country:US
Mailing Address - Phone:706-790-2030
Mailing Address - Fax:
Practice Address - Street 1:352 PACES FERRY RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-9720
Practice Address - Country:US
Practice Address - Phone:706-790-2034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities