1093879827 NPI number — HIGHLAND RIVERS CENTER, CSB

Table of content: (NPI 1093879827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093879827 NPI number — HIGHLAND RIVERS CENTER, CSB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIGHLAND RIVERS CENTER, CSB
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:
HIGHLAND RIVERS GILMER C&A SERVICES
Provider Other Organization Name Type Code:
5
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:
1093879827
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 BURLEYSON DR
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
DALTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30720-2522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-270-5002
Provider Business Mailing Address Fax Number:
706-370-7749

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18090 HIGHWAY 515 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLIJAY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30536-1331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-276-2024
Provider Business Practice Location Address Fax Number:
706-276-1502
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEAVER
Authorized Official First Name:
KLAY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
706-270-5000

Provider Taxonomy Codes

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

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

  • Identifier: 1447256243 . This is a "ORGANIZATION MASTER NPI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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