1073782447 NPI number — MCINTOSH TRAIL COMMUNITY SERVICE BOARD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073782447 NPI number — MCINTOSH TRAIL COMMUNITY SERVICE BOARD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCINTOSH TRAIL COMMUNITY SERVICE BOARD
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:
1073782447
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1501A KALAMAZOO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRIFFIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30224-3919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-358-8250
Provider Business Mailing Address Fax Number:
770-229-3223

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
403 SADDLECREEK DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCDONOUGH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30253-8916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-229-3125
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MCCOLLUM
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
770-358-8251

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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