Provider Demographics
NPI:1265410633
Name:ARCHBOLD HEALTH SERVICES, INC.
Entity type:Organization
Organization Name:ARCHBOLD HEALTH SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PERRY
Authorized Official - Last Name:MUSTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-228-2042
Mailing Address - Street 1:P.O. BOX 620
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799-0620
Mailing Address - Country:US
Mailing Address - Phone:229-228-2200
Mailing Address - Fax:229-228-2290
Practice Address - Street 1:400 OLD ALBANY ROAD
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-4013
Practice Address - Country:US
Practice Address - Phone:229-228-2200
Practice Address - Fax:229-228-2290
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARCHBOLD HEALTH SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-05
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20143096251E00000X
GA136037251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000041247AMedicaid
GA000041247BOtherCCSP (MEDICAID WAIVERED)