1194077115 NPI number — HIGHLAND RIVERS COMMUNITY SERVICE BOARD

Table of content: (NPI 1194077115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194077115 NPI number — HIGHLAND RIVERS COMMUNITY SERVICE BOARD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIGHLAND RIVERS 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:
1194077115
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 APPLEWOOD DR STE 1
Provider Second Line Business Mailing Address:
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:
706-270-5033
Provider Business Mailing Address Fax Number:
706-370-7749

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3146 MAPLE GROVE CHURCH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RESACA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30735-5036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-270-5033
Provider Business Practice Location Address Fax Number:
706-370-7749
Provider Enumeration Date:
10/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WHITLOW
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
706-270-5033

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)

  • Identifier: 000936559DR , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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