Provider Demographics
NPI:1255599346
Name:METHODIST HOME OF THE SOUTH GEORGIA CONFERENCE, INC.
Entity type:Organization
Organization Name:METHODIST HOME OF THE SOUTH GEORGIA CONFERENCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:478-464-3025
Mailing Address - Street 1:304 PIERCE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2422
Mailing Address - Country:US
Mailing Address - Phone:478-464-3025
Mailing Address - Fax:478-742-3405
Practice Address - Street 1:304 PIERCE AVENUE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204
Practice Address - Country:US
Practice Address - Phone:478-464-3025
Practice Address - Fax:478-742-3405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable