1093911265 NPI number — NORTHEAST HEALTH DISTRICT - EPSDT COUNTY

Table of content: (NPI 1093911265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093911265 NPI number — NORTHEAST HEALTH DISTRICT - EPSDT COUNTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST HEALTH DISTRICT - EPSDT COUNTY
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:
1093911265
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 867
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30642-0867
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-453-7561
Provider Business Mailing Address Fax Number:
706-453-9120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1031 APALACHEE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30642-2710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-453-7561
Provider Business Practice Location Address Fax Number:
706-453-9120
Provider Enumeration Date:
06/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOGGANS
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
S
Authorized Official Title or Position:
HEALTH DIRECTOR
Authorized Official Telephone Number:
706-583-2870

Provider Taxonomy Codes

  • Taxonomy code: 261QP0905X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000051983E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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