Provider Demographics
NPI:1801235312
Name:PAUL ANDERSON YOUTH HOME, INC.
Entity type:Organization
Organization Name:PAUL ANDERSON YOUTH HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BURRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:912-537-7237
Mailing Address - Street 1:PO BOX 525
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0525
Mailing Address - Country:US
Mailing Address - Phone:912-537-7237
Mailing Address - Fax:
Practice Address - Street 1:1603 MCINTOSH STREET
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474
Practice Address - Country:US
Practice Address - Phone:912-537-7237
Practice Address - Fax:912-537-8734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility