1558646380 NPI number — OCONEE COMMUNITY SERVICE BOARD

Table of content: (NPI 1558646380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558646380 NPI number — OCONEE COMMUNITY SERVICE BOARD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OCONEE 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:
NEW BEGINNING
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:
1558646380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1827
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILLEDGEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31059-1827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-445-4971
Provider Business Mailing Address Fax Number:
478-445-2245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 BOLAND CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31087-2007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-444-1037
Provider Business Practice Location Address Fax Number:
706-444-1034
Provider Enumeration Date:
10/12/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GHEESLING
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
B
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
478-445-4971

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: 000604469AI , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 202G709158 . This is a "MEDICARE PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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