Provider Demographics
NPI:1720071947
Name:DEPARTMENT OF BEHAVIORAL HEALTH & DEV. DISABILITIES
Entity Type:Organization
Organization Name:DEPARTMENT OF BEHAVIORAL HEALTH & DEV. DISABILITIES
Other - Org Name:SOUTHWEST DEVELOPMENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL HOSPITAL ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HILARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HOO-YOU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-227-3021
Mailing Address - Street 1:PO BOX 1378
Mailing Address - Street 2:PATIENT BILLING DEPT.
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799-1378
Mailing Address - Country:US
Mailing Address - Phone:229-227-3004
Mailing Address - Fax:227-227-2663
Practice Address - Street 1:400 S PINETREE BLVD
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-7128
Practice Address - Country:US
Practice Address - Phone:229-227-3004
Practice Address - Fax:229-227-2663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2-136-1643315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00190484AMedicaid