1043373467 NPI number — HIGHLAND RIVERS CSB

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 1043373467 NPI number — HIGHLAND RIVERS CSB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIGHLAND RIVERS 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:
Provider Other Organization Name Type Code:
6
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:
1043373467
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 APPLEWOOD DRIVE
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:
30720-2699
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:
191 LAMAR HALEY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30114-8019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-704-1600
Provider Business Practice Location Address Fax Number:
770-704-1610
Provider Enumeration Date:
12/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BEARDEN
Authorized Official First Name:
JASON
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: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000601807B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • 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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