Provider Demographics
NPI:1184997298
Name:BELAIR AT MACON
Entity type:Organization
Organization Name:BELAIR AT MACON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VANKAAT
Authorized Official - Middle Name:
Authorized Official - Last Name:SANJEEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-447-0392
Mailing Address - Street 1:4901 HARRISON RD.
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31206-4135
Mailing Address - Country:US
Mailing Address - Phone:478-476-9970
Mailing Address - Fax:478-476-4633
Practice Address - Street 1:4901 HARRISON RD.
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-4135
Practice Address - Country:US
Practice Address - Phone:478-476-9970
Practice Address - Fax:478-476-4633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011-03-008-1320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities