Provider Demographics
NPI:1811165483
Name:MCINTOSH TRAIL CSB
Entity type:Organization
Organization Name:MCINTOSH TRAIL CSB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUBBARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-358-8251
Mailing Address - Street 1:1435 N EXPRESSWAY
Mailing Address - Street 2:SUITE 301
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-9016
Mailing Address - Country:US
Mailing Address - Phone:770-358-8250
Mailing Address - Fax:770-229-3223
Practice Address - Street 1:1209 GREENBELT DR
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4507
Practice Address - Country:US
Practice Address - Phone:770-358-8258
Practice Address - Fax:770-229-3223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000601609YMedicaid