1568489904 NPI number — SAVANNAH AREA BEHAVIORAL HEALTH COLLABORTIVE

Table of content: (NPI 1568489904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568489904 NPI number — SAVANNAH AREA BEHAVIORAL HEALTH COLLABORTIVE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAVANNAH AREA BEHAVIORAL HEALTH COLLABORTIVE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568489904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 MINUS AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARDEN CITY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31408-2006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-966-3782
Provider Business Mailing Address Fax Number:
912-963-2532

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 MINIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDEN CITY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31408-2006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-966-3782
Provider Business Practice Location Address Fax Number:
912-963-2532
Provider Enumeration Date:
07/15/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
REYNOLDS
Authorized Official First Name:
JACQUILIN
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
912-966-3782

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  MSW003465 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251S00000X , with the licence number: MSW003465 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 305328035A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GRP6473 . This is a "MEDICARE GROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".