Provider Demographics
NPI:1952698227
Name:GRNCSB
Entity Type:Organization
Organization Name:GRNCSB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:TED
Authorized Official - Middle Name:M
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:770-918-6677
Mailing Address - Street 1:977A TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012
Mailing Address - Country:US
Mailing Address - Phone:770-918-6677
Mailing Address - Fax:770-918-6686
Practice Address - Street 1:977A TAYLOR STREET
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012
Practice Address - Country:US
Practice Address - Phone:770-918-6677
Practice Address - Fax:770-918-6686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service